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Lee KH, Chen KH, Ma HH, Huang TJ, Ma HL, Chiang ER. Effects of intra-articular tranexamic acid injection with different acting times after anterior cruciate ligament reconstruction: a cohort study with historical controls. J Orthop Traumatol 2025; 26:15. [PMID: 40056278 DOI: 10.1186/s10195-025-00826-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Accepted: 02/05/2025] [Indexed: 03/10/2025] Open
Abstract
BACKGROUND Intra-articular tranexamic acid (TXA) has been proven effective in reducing postoperative bleeding in anterior cruciate ligament reconstruction (ACLR). We aimed to evaluate the effect of intra-articular injection of TXA with different acting times after an ACLR procedure. PATIENTS AND METHODS Patients receiving ACLR and intra-articular injection of TXA between September 2023 and January 2024 were randomly divided into two groups, with drainage clamped for 4 h (TXA 4 h group) or 8 h (TXA 8 h group). Postoperative drainage output was the primary outcome. The secondary outcomes included the visual analog scale (VAS), grade of hemarthrosis, and International Knee Documentation Committee (IKDC) functional score. The data of another two groups of patients (TXA 2 h group and placebo group) were retrieved from a previous study as historical control groups for subsequent analysis. RESULTS 121 patients were included. There were no significant differences in drainage output between TXA 4 h and TXA 8 h groups. On postoperative day 3, significantly decreased grades of hemarthrosis were noted in the TXA 8 h group (P = 0.030). There were no significant differences in the VAS at different postoperative time points or in the IKDC scores. Comparison with the placebo and TXA 2 h groups revealed significant reduction in postoperative drainage among the TXA 4 h and 8 h groups. The IKDC scores were significantly worse in the TXA 8 h group compared with the TXA 2 h (P < 0.001) and placebo (P = 0.009) groups. CONCLUSIONS A 4 h clamping time for intra-articular TXA administration after ACLR may be considered in current practice, as it effectively reduces drainage and pain without negatively impacting functional outcomes. LEVEL OF EVIDENCE Level III, cohort study.
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Affiliation(s)
- Kun-Han Lee
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Beitou District, Taipei, Taiwan, 112, R.O.C
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kun-Hui Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Beitou District, Taipei, Taiwan, 112, R.O.C
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsuan-Hsiao Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Beitou District, Taipei, Taiwan, 112, R.O.C
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tai-Jung Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Beitou District, Taipei, Taiwan, 112, R.O.C
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsiao-Li Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Beitou District, Taipei, Taiwan, 112, R.O.C
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - En-Rung Chiang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Beitou District, Taipei, Taiwan, 112, R.O.C.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Mortada H, Hussain SA, Liyanage DD, Zou Y, Subbiah P, George J, Mansour HRK, Khajuria A. Does tranexamic acid really matter in reducing blood loss? A critical evaluation of its efficacy in orthognathic surgery through a comprehensive systematic review and meta-analysis. Br J Oral Maxillofac Surg 2024; 62:780-787. [PMID: 39266337 DOI: 10.1016/j.bjoms.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 06/29/2024] [Indexed: 09/14/2024]
Abstract
Tranexamic acid (TXA) is acknowledged for reducing blood loss and transfusion requirements in various surgical specialties, yet its role in orthognathic procedures is less defined. Our study seeks to fill this knowledge gap by reviewing the available data and summarising the efficacy and clinical outcomes of TXA in orthognathic surgery. We performed a systematic review and meta-analysis, searching five databases for studies until 16 April, 2023. Our key outcome measures were intraoperative blood loss, postoperative bleeding, and transfusion rate. Previous weaknesses in systematic review and meta-analyses (SRMA) were identified using Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2). The risk of bias was evaluated with the RoB-2 tool. A total of 15 studies were included, involving a combined total of 1060 patients. Compared with the control, the TXA group demonstrated significant reductions in intraoperative blood loss (mean difference -135.60 mL; p < 0.00001; 95% CI, -177.51 to -93.70 mL), Hb level drop (mean difference: 2.67 [-0.63, 5.98]), and improved surgical field visibility [p < 0.00001. (MD -0.99) (CI -1.11 to -0.86)]. No significant differences were observed in postoperative haematocrit levels (mean difference: -0.42 [-2.19, 1.35]; p = 0.003; I2 = 75%), operation duration (p = 0.21), or duration of hospital stay (p = 0.63) between TXA and control groups. In orthognathic surgery, TXA effectively minimises blood loss, demonstrating both safety and efficiency. Well-designed, larger studies and comparisons with other haemostatic agents could solidify TXA evidence.
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Affiliation(s)
- Hatan Mortada
- Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, King Saud University and Department of Plastic Surgery & Burn Unit, King Saud Medical City, Riyadh Saudi Arabia.
| | | | | | - Yutong Zou
- Hope College, Holland, MI, United States.
| | - Praveen Subbiah
- Broomfield Hospital, Mid and South Essex NHS Foundation Trust, Chelmsford, United Kingdom.
| | - Jefferson George
- The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, England.
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Khajuria A, Khademi Mansour HR, Muhammad I, Asare A, Tammasse I, Suresh J, Leiberman C, Pacheco-Barrios N, Brown S, Dogan T, Rohrich R. Tranexamic Acid in Rhinoplasty and Septoplasty: A Systematic Review and Meta-analysis of Randomized Controlled Trials. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6275. [PMID: 39507311 PMCID: PMC11537566 DOI: 10.1097/gox.0000000000006275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 09/05/2024] [Indexed: 11/08/2024]
Abstract
Background Perioperative bleeding is a challenge in rhinoplasty and septoplasty. Tranexamic acid (TXA) may help reduce this, but its effectiveness is unclear. This systematic review and meta-analysis aimed to evaluate TXA's impact on bleeding in these procedures. Methods The protocol was registered a priori to PROSPERO (CRD42023393458). PubMed, Embase, Google Scholar, and Web of Science were searched from inception to October 2023. Eligible studies were randomized controlled trials of adult patients undergoing rhinoplasty or septoplasty. Primary outcomes were intraoperative blood loss, surgery duration, and surgeon satisfaction. A random-effects model was used. Methodological quality was assessed using GRADE. The risk of bias was assessed using Cochrane's RoB 2 tool for randomized studies. Results The search yielded 154 results; 11 randomized controlled trials, with 968 patients, were included. The meta-analysis showed a significant reduction in intraoperative blood loss with TXA (MD -39.67; 95% CI: -15.10 to -64.24; P = 0.002) and superior surgeon satisfaction in favor of TXA use (SMD -2.73; 95% CI: -5.33 to -0.12; P = 0.04). Subgroup analyses for intraoperative blood loss, according to administration routes, were also in favor of intravenous TXA (MD -13.02; 95% CI: -1.65 to -24.38; P = 0.02) and oral TXA (MD -44.98; 95% CI: -83.66 to -6.31; P = 0.02); no statistical difference was noted in surgery duration (MD -0.99; 95% CI: 0.63 to -2.81; P = 0.23). All studies were found to be of high quality, with low bias. Conclusions The findings support TXA's efficacy in reducing blood loss during rhinoplasty and septoplasty, with high surgeon satisfaction.
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Affiliation(s)
- Ankur Khajuria
- From the Kellogg College, University of Oxford, Oxford, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | - Ibrahim Muhammad
- Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Akua Asare
- Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | | | | | | | | | - Stav Brown
- Faculty of Medical and Health Sciences, Sackler School of Medicine, Aviv University, Aviv, Israel
| | - Teoman Dogan
- Department of Plastic Surgery, American Hospital, Istanbul, Turkey
| | - Rod Rohrich
- Dallas Plastic Surgery Institute, Dallas, Tex
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Deng B, Li X, Xie P, Luo X, Yan X. Intravenous versus topical tranexamic acid in spinal surgery: a systematic review and meta-analysis. J Orthop Surg Res 2024; 19:512. [PMID: 39192283 PMCID: PMC11348596 DOI: 10.1186/s13018-024-04989-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 08/06/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND The administration of tranexamic acid (TXA) during spinal surgery has been shown to reduce blood loss. However, the efficacy and safety of intravenous TXA (ivTXA) and topical TXA (tTXA) are poorly documented. The present meta-analysis aimed to compare the efficacy and safety of ivTXA and tTXA administration in spinal surgery. METHODS Potentially relevant academic articles were identified from PubMed, Ovid, Cochrane Library, CNKI database, and Wanfang Data from the date of inception until March 1, 2024. Randomized controlled trials (RCTs) and nonrandomized controlled trials (non-RCTs) were included in our meta-analysis if they compared the efficacy and safety of ivTXA versus tTXA administration during spinal surgery. Secondary sources were identified from the references of the included literature. The meta-analysis was performed in accordance with the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. Data were summarized using RevMan 5.3 software from Denmark. RESULTS Four RCTs and one non-RCT met our inclusion criteria. The pooled outcomes demonstrated that ivTXA groups compared with tTXA groups had significantly less amount of total blood loss [weighted mean difference (WMD)=-159.55, 95% CI (-181.91,-137.19), P < 0.00001], hidden blood loss [WMD=-132.27, 95% CI (-159.81, -104.72), P < 0.00001], intraoperative blood loss [WMD=-86.22, 95% CI (-99.13, -73.31), P < 0.00001, I2 = 96%], and more high postoperative hemoglobin level [WMD = 8.96, 95% CI (5.18, 12.75), P < 0.00001, I2 = 29%], and less transfusion rate [risk ratio (RR) = 1.11, 95% CI (0.81,1.52), P = 0.50, I2 = 94%]. The pooled results showed no significant difference in thromboembolic events (deep venous thrombosis and pulmonary embolism) between the two groups. CONCLUSION Our meta-analysis demonstrated that ivTXA was more effective than tTXA in inducing hemostatic effect during spinal surgery. However, the risk of a thrombotic event was not different between the two administration methods of TXA. More high quality RCTs are needed to further confirm our conclusions.
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Affiliation(s)
- Bo Deng
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Xudong Li
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Peng Xie
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Xiaozhong Luo
- Orthopedics Department, The Seven Affiliated Hospital of South China University, Changsha, 410000, China
| | - Xueliang Yan
- Department of Spine Surgery, The Second Affiliated Hospital of South China University, Hengyang, 421000, China.
- School of Life Science, Central South University, Changsha, 410000, China.
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Cartagena-Reyes MA, Silva-Aponte JA, Nazario-Ferrer GI, Benes GA, Choudhary A, Raad M, Frank SM, Musharbash FN, Jain A. The cost-utility of intraoperative tranexamic acid in adult spinal deformity patients undergoing long posterior spinal fusion. Spine Deform 2024; 12:587-593. [PMID: 38427155 DOI: 10.1007/s43390-023-00818-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 12/29/2023] [Indexed: 03/02/2024]
Abstract
PURPOSE This study aims to evaluate the cost-utility of intraoperative tranexamic acid (TXA) in adult spinal deformity (ASD) patients undergoing long posterior (≥ 5 vertebral levels) spinal fusion. METHODS A decision-analysis model was built for a hypothetical 60-year-old adult patient with spinal deformity undergoing long posterior spinal fusion. A comprehensive review of the literature was performed to obtain event probabilities, costs and health utilities at each node. Health utilities were utilized to calculate Quality-Adjusted Life Years (QALYs). A base-case analysis was carried out to obtain the incremental cost and effectiveness of intraoperative TXA. Probabilistic sensitivity analysis was performed to evaluate uncertainty in our model and obtain mean incremental costs, effectiveness, and net monetary benefits. One-way sensitivity analyses were also performed to identify the variables with the most impact on our model. RESULTS Use of intraoperative TXA was the favored strategy in 88% of the iterations. The mean incremental utility ratio for using intraoperative TXA demonstrated higher benefit and lower cost while being lower than the willingness-to-pay threshold set at $50,000 per quality adjusted life years. Use of intraoperative TXA was associated with a mean incremental net monetary benefit (INMB) of $3743 (95% CI 3492-3995). One-way sensitivity analysis reported cost of blood transfusions due to post-operative anemia to be a major driver of cost-utility analysis. CONCLUSION Use of intraoperative TXAs is a cost-effective strategy to reduce overall perioperative costs related to post-operative blood transfusions. Administration of intraoperative TXA should be considered for long fusions in ASD population when not explicitly contra-indicated due to patient factors.
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Affiliation(s)
- Miguel A Cartagena-Reyes
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Juan A Silva-Aponte
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Gabriel I Nazario-Ferrer
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Gregory A Benes
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Ananya Choudhary
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University, 1800 Orleans St., Zayed 6208, Baltimore, MD, 21287, USA
| | - Farah N Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, JHOC 5230, Baltimore, MD, 21287, USA.
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Aghajanian S, Mohammadifard F, Kohandel Gargari O, Naeimi A, Bahadorimonfared A, Elsamadicy AA. Efficacy and utility of antifibrinolytics in pediatric spine surgery: a systematic review and network meta-analysis. Neurosurg Rev 2024; 47:177. [PMID: 38644447 DOI: 10.1007/s10143-024-02424-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/09/2024] [Accepted: 04/16/2024] [Indexed: 04/23/2024]
Abstract
Antifibrinolytics have gained increasing attention in minimizing blood loss and mitigating the risks associated with massive transfusions, including infection and coagulopathy in pediatric patients undergoing spine surgery. Nevertheless, the selection of optimal agent is still a matter of debate. We aim to review the utility of these agents and compare the efficacy of antifibrinolytics in pediatric and adolescent spine surgeries. A comprehensive search was performed in Scopus, Web of Science, and MEDLINE databases for relevant works. Studies providing quantitative data on predefined outcomes were included. Primary outcome was perioperative bleeding between the groups. Secondary outcomes included transfusion volume, rate of complications, and operation time. Twenty-eight studies were included in the meta-analysis incorporating 2553 patients. The use of Tranexamic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 88%), Aprotinin (RoM: 0.54, 95%CI: [0.46-0.64], p < 0.001, I2 = 0%), and Epsilon-aminocaproic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 60%) led to a 29%, 46%, and 29% reduction in perioperative blood loss, respectively. Network meta-analysis revealed higher probability of efficacy with Tranexamic acid compared to Epsilon-aminocaproic acid (P score: 0.924 vs. 0.571). The rate of complications was not statistically different between each two antifibrinolytic agent or antifibrinolytics compared to placebo or standard of care. Our network meta-analysis suggests a superior efficacy of all antifibrinolytics compared to standard of care/placebo in reducing blood loss and transfusion rate. Further adequately-powered randomized clinical trials are recommended to reach definite conclusion on comparative performance of these agents and to also provide robust objective assessments and standardized outcome data and safety profile on antifibrinolytics in pediatric and adolescent pediatric surgeries.
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Affiliation(s)
- Sepehr Aghajanian
- School of Medicine, Alborz University of Medical Sciences, Karaj, Iran.
- Neuroscience Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | | | - Omid Kohandel Gargari
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
- Headache Research Center, Neurology Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Arvin Naeimi
- Student Research Committee, School of Medicine, Guilan University of Medical Sciences, Rasht, Gilan, Iran
| | - Ayad Bahadorimonfared
- Department of Health & Community Medicine, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
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Zahra W, Nayar SK, Bhadresha A, Jasani V, Aftab S. Safety of tranexamic acid in surgically treated isolated spine trauma. World J Orthop 2024; 15:346-354. [PMID: 38680673 PMCID: PMC11045465 DOI: 10.5312/wjo.v15.i4.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/07/2024] [Accepted: 03/19/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Tranexamic acid (TXA), a synthetic antifibrinolytic drug, effectively reduces blood loss by inhibiting plasmin-induced fibrin breakdown. This is the first study in the United Kingdom to investigate the effectiveness of TXA in the surgical management of isolated spine trauma. AIM To assess the safety of TXA in isolated spine trauma. The primary and secondary outcomes are to assess the rate of thromboembolic events and to evaluate blood loss and the incidence of blood transfusion, respectively. METHODS This prospective observational study included patients aged ≥ 17 years with isolated spine trauma requiring surgical intervention over a 6-month period at two major trauma centers in the United Kingdom. RESULTS We identified 67 patients: 26 (39%) and 41 (61%) received and did not receive TXA, respectively. Both groups were matched in terms of age, gender, American Society of Anesthesiologists grade, and mechanism of injury. A higher proportion of patients who received TXA had a subaxial cervical spine injury classification or thoracolumbar injury classification score > 4 (74% vs 56%). All patients in the TXA group underwent an open approach with a mean of 5 spinal levels involved and an average operative time of 203 min, compared with 24 patients (58%) in the non-TXA group who underwent an open approach with an average of 3 spinal levels involved and a mean operative time of 159 min. Among patients who received TXA, blood loss was < 150 and 150-300 mL in 8 (31%) and 15 (58%) patients, respectively. There were no cases of thromboembolic events in any patient who received TXA. CONCLUSION Our study demonstrated that TXA is safe for isolated spine trauma. It is challenging to determine whether TXA effectively reduces blood loss because most surgeons prefer TXA for open or multilevel cases. Further, larger studies are necessary to explore the rate, dosage, and mode of administration of TXA.
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Affiliation(s)
- Wajiha Zahra
- Trauma and Orthopedics Department, University Hospital of North Midlands NHS Trust, Stoke-on-Trent ST4 6QG, United Kingdom
| | - Sandeep Krishan Nayar
- Trauma and Orthopedics Department, Royal London Hospital, Barts Health Institute, London E1 1BB, United Kingdom
| | - Ashwin Bhadresha
- Trauma and Orthopedics Department, Royal London Hospital, Barts Health Institute, London E1 1BB, United Kingdom
| | - Vinay Jasani
- Craniospinal Services, University Hospital of North Midlands NHS Trust, Stoke-on-Trent ST4 6QG, United Kingdom
| | - Syed Aftab
- Spine Department, Royal London Hospital, Barts Health Institute, London E1 1BB, United Kingdom
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Zuccon A, Rogério Cardozo Kanaji P, Serafini Barcellos D, Zabulon S, de Oliveira Saraiva A, Yoshi de Freitas TA. Tranexamic Acid in Hip Reconstructions in Children with Cerebral Palsy: A Double-Blind Randomized Controlled Clinical Trial. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1931. [PMID: 38136133 PMCID: PMC10742497 DOI: 10.3390/children10121931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/24/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023]
Abstract
Surgical treatment is indicated for hip dislocation in patients with cerebral palsy (CP), but it requires care due to the state of nutrition and associated clinical comorbidities. The use of resources that minimize blood loss and the need for blood transfusions are essential to avoid complications. Tranexamic acid (TXA) has been highlighted for orthopedic surgeries to control intraoperative bleeding; however, there is a lack of large studies for its use in hip surgeries in patients with CP. This study aims to evaluate the efficacy and safety of tranexamic acid to reduce bleeding in pediatric patients with cerebral palsy undergoing surgical treatment for hip instability. A sample of 31 patients with CP who underwent surgical treatment for hip dislocation (hip adductor stretching, varization osteotomy of the proximal femur and acetabuloplasty using the Dega technique) was randomly divided into groups: control (n = 10) and TXA (n = 21). Preoperative and 24 h hemoglobin concentrations, the length of hospital stay (LHS), and intraoperative bleeding (IB) were analyzed. TXA significantly reduced the IB (p = 0.02). The variance in hemoglobin concentration was lower for the TXA group, but without statistical significance (p = 0.06). There was no difference in LHS. Also, no statistical difference was observed for the number of transfusions (p = 0.08). The findings provide evidence of the effectiveness of TXA in decreasing intraoperative bleeding and its safety for use in pediatric patients with cerebral palsy.
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Affiliation(s)
- Alexandre Zuccon
- Disabled Children’s Care Association of São Paulo (AACD-SP), São Paulo 04027-000, Brazil; (P.R.C.K.); (D.S.B.); (S.Z.); (A.d.O.S.); (T.A.Y.d.F.)
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Abdallah Z, Staibano P, Zhou K, Khalife S, Nguyen TBV, Sommer DD. Tranexamic acid in endoscopic sinus and skull base surgery: A systematic review and meta-analysis. Int Forum Allergy Rhinol 2023; 13:2187-2204. [PMID: 37259887 DOI: 10.1002/alr.23203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/24/2023] [Accepted: 05/26/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Endoscopic sinus surgery (ESS) and endoscopic skull base surgery (ESBS) approaches have revolutionized the management of sinonasal and intracranial pathology. Maintaining surgical hemostasis is essential as bleeding can obscure the visibility of the surgical field, thus increasing surgical duration, risk of complications, and procedural failure. Tranexamic acid (TXA) acts to reduce bleeding by inhibiting fibrin degradation. This review aims to assess whether TXA improves surgical field quality and reduces intraoperative blood loss compared with control. METHODS We searched PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library from inception until September 1, 2022. Two reviewers independently screened citations, extracted data, and assessed methodological quality using the Cochrane risk-of-bias tool for randomized trials. Data were pooled using a random-effect model, with continuous data presented as mean differences and dichotomous data presented as odds ratios. RESULTS Seventeen ESS randomized controlled trials (n = 1377) and one ESBS randomized controlled trial (n = 50) were reviewed. Significant improvement in surgical field quality was achieved with both systemic TXA (six studies, p < 0.00001) and topical TXA (six studies, p = 0.01) compared with the control. Systemic TXA (eight studies) and topical TXA (three studies) both achieved a significant reduction in intraoperative blood loss compared with the control (p < 0.00001). There were significant differences in operative times (p < 0.001) but no significant difference in perioperative outcomes (p = 0.30). CONCLUSION This meta-analysis demonstrated that the administration of TXA in ESS can improve surgical field quality and reduce intraoperative blood loss. TXA use did not result in increased perioperative complications including thrombotic events.
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Affiliation(s)
- Zahra Abdallah
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Phillip Staibano
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kelvin Zhou
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Khalife
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Thomas B V Nguyen
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Doron D Sommer
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
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Ji X, Wang X, Shi L, Tian F. Postoperative clinical outcomes with and without short-term intravenous tranexamic acid after posterior lumbar interbody fusion: A prospective cohort study. Medicine (Baltimore) 2023; 102:e35911. [PMID: 37986288 PMCID: PMC10659680 DOI: 10.1097/md.0000000000035911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 11/22/2023] Open
Abstract
The use of tranexamic acid (TXA) in posterior lumbar interbody fusion (PLIF) surgery is believed to be beneficial for reducing intraoperative blood loss, postoperative drainage volume (PDV), and length of hospital stay (LOS). However, whether continued administration of intravenous TXA within 24 hours after surgery is more beneficial to patients has not yet been studied. This study prospectively analyzed the perioperative outcomes of patients who received and did not receive intravenous TXA within 24 hours after PLIF (≥2 segments) surgery from January 2018 to December 2021. A total of 78 and 69 patients were included in the TXA (receive intravenous TXA intraoperatively and within 24 hours postoperatively) and non-TXA (only receive intravenous TXA intraoperatively) groups, respectively. No significant differences were observed in the intraoperative blood loss and operative time between the 2 groups. The postoperative drainage volume, postoperative drainage time, and length of hospital stay in the TXA group were significantly lower than those in the non-TXA group. The rates and volumes of postoperative blood and albumin transfusions were significantly lower in the TXA group than those in the non-TXA group. No significant differences were observed in the perioperative complication rates between the 2 groups. No increase in thrombosis-related complications was observed with postoperative TXA administration. Short-term TXA use after PLIF (≥2 segments) surgery is safe. In addition to intraoperative use of TXA, additionally administration of intravenous TXA within 24 hours postoperatively can improve the perioperative clinical outcomes of patients without increasing the risk of thrombotic events.
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Affiliation(s)
- Xianqun Ji
- Department of Orthopedics, Xiangyang No. 1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
| | - Xiaochen Wang
- Department of Pharmacy, Shengli Oilfield Central Hospital, Dongying, Shandong, China
| | - Liang Shi
- Department of Orthopedics, Xiangyang No. 1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
| | - Fangtao Tian
- Department of Orthopedics, Xiangyang No. 1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
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11
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van Kouswijk HW, Tolk JJ, van Bommel CPE, Reijman M, Kempink DRJ, de Witte PB. Effect of tranexamic acid on intraoperative blood loss in pediatric osteotomies around the hip: Study protocol for a double-blind randomized placebo-controlled trial. J Child Orthop 2023; 17:404-410. [PMID: 37799317 PMCID: PMC10549700 DOI: 10.1177/18632521231199518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/19/2023] [Indexed: 10/07/2023] Open
Abstract
Background Proximal femoral and/or pelvic osteotomies (PFPOs) can be indicated for a multitude of hip pathologies in (often asymptomatic) children, to prevent future hip problems. These procedures can result in significant blood loss. Tranexamic acid (TXA) is an antifibrinolytic agent routinely administered in adult trauma and joint reconstruction surgery to reduce blood loss. TXA is also registered for use in children and reported safe and beneficial for pediatric trauma, cardiac, and spinal surgery. However, for pediatric orthopedics, particularly for PFPOs, the available evidence is limited. Therefore, the current trial will investigate the potential reducing effect of preoperative TXA on intraoperative blood loss in pediatric PFPOs. Methods In this single-center, double-blind, randomized placebo-controlled trial, we aim to include 180 participants aged from 1 to 18 years undergoing PFPOs for any indication at our institution. Participants will be randomized to receive either TXA or placebo (saline) during anesthetic induction. The primary outcome is intraoperative estimated blood loss (mL/kg), which is determined gravimetrically. Secondary outcomes include the percentage of patients with excessive blood loss (>20 mL/kg), procedure time and hospital stay, and postoperative hemoglobin level changes. Discussion This will be the first prospective study investigating the effect of preoperative TXA on intraoperative blood loss in pediatric PFPOs. Its results will help to determine whether it would be advisable to adopt preoperative TXA as a standard medication to minimize blood loss and prevent complications in this vulnerable population. Trial registration EudraCT: 2022-002384-30. Prospectively registered on September 26, 2022.
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Affiliation(s)
- Hilde W van Kouswijk
- Department of Orthopaedics and Sports Medicine, Erasmus MC—Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Orthopaedic Surgery, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Jaap J Tolk
- Department of Orthopaedics and Sports Medicine, Erasmus MC—Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Christian PE van Bommel
- Department of Hospital Pharmacy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Max Reijman
- Department of Orthopaedics and Sports Medicine, Erasmus MC—Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Dagmar RJ Kempink
- Department of Orthopaedics and Sports Medicine, Erasmus MC—Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Pieter B de Witte
- Department of Orthopaedics and Sports Medicine, Erasmus MC—Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
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12
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Jakoi AM, Kirchner GJ, Lieber AM, Khalsa AS. Marijuana Use is Not a Contraindication for Tranexamic Acid Utilization in Lumbar Spine Surgery. Global Spine J 2023; 13:1771-1776. [PMID: 35014544 PMCID: PMC10556919 DOI: 10.1177/21925682211049166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The purpose of this study was to evaluate safety in lumbar spinal fusion with tranexamic acid (TXA) utilization in patients using marijuana. METHODS This was a retrospective cohort study involving a single surgeon's cases of 1 to 4 level lumbar fusion procedures. Two hundred and ninety-four patients were followed for ninety days post-operatively. Consecutive patients were self-reported for daily marijuana use (n = 146) and compared to a similar cohort of patients who denied usage of marijuana (n = 146). Outcomes were collected, which included length of stay (LOS), estimated blood loss (EBL), post-operative myocardial infarction, seizures, deep venous thrombosis, pulmonary embolus, death, readmission, need for further surgery, infection, anaphylaxis, acute renal injury, and need for blood product transfusion. RESULTS Patients in the marijuana usage cohort had similar age (58.9 years ±12.9 vs 58.7 years ±14.8, P = .903) and distribution of levels fused (P = .431) compared to the non-usage cohort. Thromboembolic events were rare in both groups (marijuana usage: 1 vs non-usage: 2). Compared to the non-usage cohort, the marijuana usage cohort had a similar average EBL (329.9 ± 298.5 mL vs 374.5 ± 363.8 mL; P = .254). Multivariate regression modeling demonstrated that neither EBL (OR 1.27, 95% CI 0.64-2.49) nor need for transfusion (OR 1.56, 95% CI 0.43-5.72) varied between cohorts. The non-usage cohort had twice the risk of prolonged LOS compared to the marijuana usage cohort (OR 2.05, 95% CI 1.15-3.63). CONCLUSION Marijuana use should not be considered a contraindication for TXA utilization in lumbar spine surgery.
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Affiliation(s)
| | - Gregory J. Kirchner
- Department of Orthopaedic Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Alexander M. Lieber
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amrit S. Khalsa
- Department of Orthopaedic Surgery, The University of Pennsylvania, Philadelphia, PA, USA
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13
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Posterior Preventive Foraminotomy before Laminectomy Combined with Pedicle Screw Fixation May Decrease the Incidence of C5 Palsy in Complex Cervical Spine Surgery in Patients with Severe Myeloradiculopathy. J Clin Med 2023; 12:jcm12062227. [PMID: 36983227 PMCID: PMC10058652 DOI: 10.3390/jcm12062227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/16/2023] Open
Abstract
C5 palsy is a frequent sequela of cervical decompression surgeries for cervical myeloradiculopathy. Although many researchers have suggested various risk factors, such as cord shifting and the correction of lordotic angles, the tethering of the C5 root beneath the narrow foramen is an independent risk factor for C5 palsy. In this study, we tried to investigate different techniques for foramen decompression with posterior cervical fusion and assess the incidence of C5 palsy with each technique depending on the order of foraminal decompression. A combined 540° approach with LMS and uncovertebrectomy was used in group 1. Group 2 combined a 540° approach with pedicle screws and posterior foraminotomy, while posterior approach only with pedicle screws and foraminotomy was used in group 3. For groups 2 and 3, prophylactic posterior foraminotomy was performed before laminectomy. Motor manual testing to assess C5 palsy, the Neck Disability Index (NDI) and the Japanese Orthopedic Association (JOA) scores were determined before and after surgery. Simple radiographs, MRI and CT scans, were obtained to assess radiologic parameters preoperatively and postoperatively. A total of 362 patients were enrolled in this study: 208 in group 1, 72 in group 2, and 82 in group 3. The mean age was 63.2, 65.5, and 66.6 years in groups 1, 2, and 3, respectively. The median for fused levels was 4 for the three groups. There was no significant difference between groups regarding the number of fused levels. Weight, height, comorbidities, and diagnosis were not significantly different between groups. Preoperative JOA scores were similar between groups (p = 0.256), whereas the preoperative NDI score was significantly higher in group 3 than in group 2 (p = 0.040). Mean JOA score at 12-month follow-up was 15.5 ± 1.89, 16.1 ± 1.48, and 16.1 ± 1.48 for groups 1, 2, and 3, respectively; it was higher in group 3 compared with group 1 (p = 0.008) and in group 2 compared with group 1 (p = 0.024). NDI score at 12 months was 13, 12, and 13 in groups 1, 2, and 3, respectively; it was significantly better in group 3 than in group 1 (p = 0.040), but there were no other significant differences between groups. The incidence of C5 palsy was significantly lower in posterior foraminotomy groups with pedicle screws (groups 2 and 3) than in LMS with uncovertebrectomy (group 1) (p < 0.001). Thus, preventive expansive foraminotomy before decompressive laminectomy is able to significantly decrease the root tethering by stenotic lesion, and subsequently, decrease the incidence of C5 palsy associated with posterior only or combined posterior and anterior cervical fusion surgeries. Additionally, such expansive foraminotomy might be appropriate with pedicle screw insertion based on biomechanical considerations.
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14
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Takahashi R, Kajita Y, Iwahori Y, Harada Y. Tranexamic acid administration for arthroscopic rotator cuff repair: A prospective, double-blind, randomized controlled trial. J Orthop Sci 2023; 28:328-332. [PMID: 34949506 DOI: 10.1016/j.jos.2021.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/22/2021] [Accepted: 11/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to compare the efficacy of tranexamic acid versus placebo after arthroscopic rotator cuff repair. METHODS This prospective, double-blind, and randomized study involved 66 patients who consecutively underwent arthroscopic rotator cuff repair from 2020 to 2021 at our hospital. Thirty-three shoulders each were randomly assigned to the tranexamic acid and control groups. In the former group, 1000 mg of tranexamic acid (20 mL) was administered intravenously 10 min before surgery and the same volume of normal saline (20 mL) was administered intravenously in the control group. We evaluated visual clarity; visual analog scale pain scores at rest, during activity, and at night; the circumference and diameter of the shoulder joint in the groups before and after the surgery at 1, 2, and 3 days, and 1 week; estimated perioperative blood loss; and operative time. Visual clarity was rated using a numeric rating scale from grade 1 (poor) to grade 3 (clear) every 15 min throughout the surgery. We compared and analyzed the results between the groups. Statistical significance was set at a p-value of <0.05. RESULTS Visual clarity was found to be significantly better in the tranexamic acid group, with a greater percentage of grade 3 visual clarity (75.6 ± 11.2% vs 68.1 ± 13.4%, p = 0.045). The visual analog scale scores at rest and at night in the control group were significantly lower than those in the tranexamic acid group for 1 week postoperatively (13.8 ± 14.8 vs 5 ± 9.3, p = 0.008, 36.1 ± 23.3 vs 19.3 ± 24, p = 0.012). The circumference and diameter of the shoulder joint, estimated perioperative blood loss, and operative time were not significantly different between the two groups. CONCLUSION Intravenous administration of tranexamic acid is an alternative way to improve visual clarity in arthroscopic rotator cuff repair; however, there are no other significant differences compared to the administration of placebo.
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Affiliation(s)
- Ryosuke Takahashi
- Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, Japan.
| | - Yukihiro Kajita
- Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, Japan; Department of Orthopaedic Surgery, Aichi Medical University, Japan.
| | - Yusuke Iwahori
- Department of Orthopaedic Surgery, Asahi Hospital, Japan.
| | - Yohei Harada
- Department of Orthopaedic Surgery, Hiroshima University, Japan.
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15
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Rajabifard P, Cunningham JE, Johnson MA, Bäcker HC, Turner P. Blood Loss Following Open Posterior Spinal Fusion in Fractures: Cannulated vs. Solid Pedicle Screws. J Pers Med 2023; 13:jpm13010160. [PMID: 36675821 PMCID: PMC9861553 DOI: 10.3390/jpm13010160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
We aim to delineate whether there is increased blood loss with the use of cannulated pedicle screws compared to solid pedicle screws in patients undergoing posterior spinal fusion. A single-centre retrospective case-control study was undertaken on patients undergoing PSF for spinal fractures. Cannulated screw fixation was compared with solid screw fixation. Intraoperative blood loss was estimated using pre and postoperative haemoglobin levels, recorded estimated blood loss and cell saver reports. Anticoagulation, blood product administration, operative time and number of levels fused were assessed. A total of 64 cases, 32 in each cohort, were included in the analysis. Overall mean haemoglobin reduction from pre- to post-operative was 2.82 ± 1.85 g/L per screw inserted in the cannulated group, compared to a haemoglobin decrease of 2.81 ± 1.521 g/L per screw inserted in the solid screw group (p = 0.971). Total estimated intraoperative blood loss was 616.3 + 355.4 mL in the cannulated group, compared to 713.6 + 473.5 mL in the solid screw group (p = 0.456). Patients with preoperative thrombocytopenia had a transfusion rate of 0.5 ± 0.71 units/patient compared to 0.04 ± 0.19 units/patient in patients with normal platelet levels (p < 0.005). The differences in blood loss observed between cannulated and solid pedicle screws are non-significant overall. The largest predictor for need of transfusion was pre-operative thrombocytopenia, regardless of the type of screw used.
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Affiliation(s)
- Pedram Rajabifard
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
| | - John Edward Cunningham
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
| | - Michael A. Johnson
- Department of Orthopaedic Surgery, Epworth Richmond Hospital, 89 Bridge Road, Richmond, VIC 3121, Australia
| | - Henrik Constantin Bäcker
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
- Department of Orthopaedic Surgery, Epworth Richmond Hospital, 89 Bridge Road, Richmond, VIC 3121, Australia
- Centre for Musculoskeletal Surgery, Charite Berlin, Chariteplatz 1, 10117 Berlin, Germany
- Correspondence:
| | - Peter Turner
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
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16
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Butler AJ, Donnally CJ, Goz V, Basques BA, Vaccaro AR, Schroeder GD. Symptomatic Postoperative Epidural Hematoma in the Lumbar Spine. Clin Spine Surg 2022; 35:354-362. [PMID: 34923504 DOI: 10.1097/bsd.0000000000001278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 09/15/2021] [Indexed: 01/25/2023]
Abstract
A symptomatic postoperative epidural hematoma (SPEH) in the lumbar spine is a complication with variable presentation and the potential to rapidly cause an irrecoverable neurological injury. Significant heterogeneity exists among current case series reporting SPEH in the literature. This review attempts to clarify the known incidence, risk factors, and management pearls. Currently, literature does not support the efficacy of subfascial drains in reducing the incidence of SPEHs and possibly suggests that medication for thromboembolism prophylaxis may increase risk. Acute back pain and progressing lower extremity motor weakness are the most common presenting symptoms of SPEH. Magnetic resonance imaging is the mainstay of diagnostic imaging necessary to confirm the diagnosis, but if not acutely available, an immediate return to the operative theater for exploration without advanced imaging is justified. Treatment of a SPEH consists of emergent hematoma evacuation as a delay in repeat surgery has a deleterious effect on neurological recovery. Outcomes are poorly defined, though a significant portion of patients will have lasting neurological impairments even when appropriately recognized and managed.
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Affiliation(s)
- Alexander J Butler
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, FL
| | - Chester J Donnally
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Vadim Goz
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Bryce A Basques
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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17
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Clohisy JCF, Lenke LG, Dafrawy MHE, Wolfe RC, Frazier E, Kelly MP. Randomized, controlled trial of two tranexamic acid dosing protocols in adult spinal deformity surgery. Spine Deform 2022; 10:1399-1406. [PMID: 35751772 DOI: 10.1007/s43390-022-00539-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/28/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an anti-fibrinolytic effective in reducing blood loss in orthopedic surgery. The appropriate dosing protocol for adult spinal deformity (ASD) surgery is not known. The purpose of this study was to evaluate two TXA protocols [low dose (L): 10 mg/kg bolus, 1 mg/kg/hr infusion; high dose (H): 50 mg/kg, 5 mg/kg/hr] in complex ASD surgery. METHODS Inclusion criteria were ASD reconstructions with minimum 10 fusion levels or planned 3-column osteotomy (3CO). Standard demographic and surgical data were collected. Intraoperative estimated blood loss (EBL) was calculated by suction canisters minus irrigation plus estimated blood lost in sponges, estimated to the nearest 50 mL. Serious adverse events (SAE) were defined a priori as: venothromboembolic event (VTE), cardiac arrhythmia, myocardial infarction, renal dysfunction, and seizure. All SAE were recorded. Simple t tests compared EBL between groups. Mean EBL by total blood volume (TBV), transfusion volume, complications related to TXA were secondary outcomes. RESULTS Sixty-two patients were enrolled and 52 patients completed the study; 25 were randomized to H and 27 to L. Demographic and surgical variables were not different between the two groups. EBL was not different between groups (H: 1596 ± 933 cc, L: 2046 ± 1105 cc, p = 0.12, 95% CI: - 1022 to 122 cc). EBL as a percentage of TBV was lower for the high-dose group (H: 29.5 ± 14.8%, L: 42.5 ± 26.2%, p = 0.03). Intraoperative transfusion volume (H: 961 ± 505 cc, L: 1105 ± 808 cc, p = 0.5) and post-operative transfusion volume (H: 513 ± 305 cc, L: 524 ± 245 cc, p = 0.9) were not different. SAE related to TXA were not different (p = 0.7) and occurred in 2 (8%) H and 3 (11%) L. There was one seizure (H), 2 VTE, and 2 arrhythmias. CONCLUSION No differences in EBL, transfusion volume, nor SAE were observed between H and L dose TXA protocols. High dose was associated with decreased TBV loss (13%). Further prospective study, with pharmacologic analysis, is required to determine appropriate TXA dosage in ASD surgeries. LEVEL OF EVIDENCE Therapeutic Level II. TRIAL REGISTRATION The study was registered at Clinicaltrials.gov (NCT02053363) February 3, 2014.
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Affiliation(s)
- John C F Clohisy
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Rachel C Wolfe
- Perioperative Services and Surgical Critical Care, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Elfaridah Frazier
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael P Kelly
- Rady Children's Hospital, University of California, 3020 Children's Way, San Diego, CA, 92123, USA.
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18
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Kanhere AP, Lambrechts MJ, Issa TZ, Karamian BA, Hendow CJ, Reddy YC, Slota PJ, D'Antonio ND, Kaye ID, Canseco JA, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. The Effect of Tranexamic Acid on Operative and Postoperative Blood Loss in Transforaminal Lumbar Interbody Fusions. World Neurosurg 2022; 166:e443-e450. [PMID: 35840090 DOI: 10.1016/j.wneu.2022.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of this retrospective cohort study was to evaluate the effect of tranexamic acid (TXA) on reducing perioperative blood loss and length of stay after transforaminal lumbar interbody fusion (TLIF). Spine surgery is associated with the potential for significant blood loss, and adequate hemostasis is essential to visualizing crucial structures during the approach and procedure. Although TXA use has been extensively studied in the pediatric and adult spinal deformity literature, there is a dearth of literature on its efficacy in reducing blood loss for patients who undergo 1- to 3-level TLIF. METHODS All patients requiring 1- to 3-level TLIF who received a preoperative loading dose of TXA were grouped and compared with patients who didn't receive TXA. Demographic, surgical, and laboratory values were collected and analyzed. Continuous and categorical variables were analyzed with χ2, Kruskal-Wallis, or analysis of variance tests, depending on normality and data type. Multiple linear regressions were developed to determine independent predictors of the estimated blood loss (EBL), total blood loss, drain output, and length of stay. Statistical significance was set at P < 0.05. RESULTS Patients who received preoperative TXA had more comorbidities (P = 0.006), longer surgery length (P < 0.001), and longer length of stay (P = 0.004). TXA was independently associated with a decreased day 0, 1, 2, and total drain output (P < 0.001, P = 0.001, P = 0.007, P < 0.001, respectively), but was not associated with a change in EBL, total blood loss, or length of stay. CONCLUSIONS The application of preoperative TXA for patients undergoing 1- to 3-level TLIF reduced drain output in the first 2 postoperative days, but it did not affect hospital length of stay, total blood loss, or EBL.
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Affiliation(s)
- Arun P Kanhere
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Tariq Ziad Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chelsea J Hendow
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yashas C Reddy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paul J Slota
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nicholas D D'Antonio
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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19
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Abdou M, Kwon JW, Kim HJ, Lee B, Choi YS, Moon SH, Lee BH. Tranexamic Acid and Intraoperative and Postoperative Accumulative Bleeding in Elective Degenerative Spine Surgery. Yonsei Med J 2022; 63:927-932. [PMID: 36168245 PMCID: PMC9520043 DOI: 10.3349/ymj.2022.0163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/07/2022] [Accepted: 08/02/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Spinal surgeries are often associated with a high incidence of perioperative blood loss, which poses several complications. Much current research focuses on the importance of antifibrinolytic drugs during spinal surgeries to reduce blood loss, which can also reduce the risk of the need for blood transfusions. We evaluated the effects of prophylactic, low-dose tranexamic acid (TXA) in spinal fusion surgeries on blood loss, blood transfusions, and associated complications. MATERIALS AND METHODS TXA was administered to 90 patients at a constant infusion rate of 10 mg/kg for 20 minutes after anesthesia induction, followed by a maintenance dose of 1 mg/kg/h until the end of the operation. An additional 91 patients were included as controls. RESULTS There were no significant differences between the study groups in terms of intraoperative blood loss, which was 500 mL for both groups (p>0.999). Also, intraoperative blood transfusion requirements were similar between both groups (p=0.330). Mean blood transfusion amounts were 125±35 mL for patients in the TXA group and 85±25 mL in the control group. However, there was a significant reduction in postoperative blood transfusion (p=0.003) in the TXA group. Only three cases in the TXA group required blood transfusion, while 15 cases in the control group did. CONCLUSION We confirmed that low dose TXA has no effect on intraoperative blood loss volume or blood transfusion requirements and that it can significantly reduce the need for postoperative blood transfusions.
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Affiliation(s)
- Mahmoud Abdou
- Department of Orthopedic Surgery, Fayoum University College of Medicine, Fayoum, Egypt
| | - Ji-Won Kwon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Jin Kim
- Department of Anesthesia, Yonsei University College of Medicine, Seoul, Korea
| | - Bora Lee
- Department of Anesthesia, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Seon Choi
- Department of Anesthesia, Yonsei University College of Medicine, Seoul, Korea
| | - Seong-Hwan Moon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Ho Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea.
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20
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Johns WL, Walley KC, Jackson B, Gonzalez TA. Tranexamic Acid in Foot and Ankle Surgery: A Topical Review and Value Analysis. Foot Ankle Spec 2022; 15:377-383. [PMID: 33401927 DOI: 10.1177/1938640020983639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tranexamic acid (TXA) has become a commonly used perioperative intervention in total joint arthroplasty, shoulder and knee arthroscopy, and spinal procedures in order to minimize blood loss, hematoma formation, hemarthrosis, and wound healing complications. There is a potential role for TXA use in foot and ankle procedures, with limited studies suggesting a potential benefit in minimizing postoperative wound complications and blood loss without an increased risk of thromboembolic events. In light of the profound clinical and financial impact of TXA use in other orthopaedic subspecialties and the early successes in foot and ankle surgery, we aim to provide more information about TXA and its use in foot and ankle surgery. Therefore, the purpose of this review is to perform a comprehensive literature review on the topic of TXA use in foot and ankle procedures in order to describe the pertinent available literature on the use of TXA in orthopaedic surgery and its implications specifically in foot and ankle surgery. It is our aim to identify potential benefits and shortcomings in the available evidence on TXA use for foot and ankle surgery in hopes to (1) best inform foot and ankle surgeons where beneficial and safe and (2) inspire further research on this topic as it relates to clinical management for foot and ankle patients.Levels of Evidence: Level IV.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Kempland C Walley
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Benjamin Jackson
- School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Tyler A Gonzalez
- School of Medicine, University of South Carolina, Columbia, South Carolina
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21
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Ivasyk I, Chatterjee A, Jordan C, Geiselmann MT, Chang PS, Kamel H, Khormaee S. Evaluation of the safety of tranexamic acid use in pediatric patients undergoing spinal fusion surgery: a retrospective comparative cohort study. BMC Musculoskelet Disord 2022; 23:651. [PMID: 35804327 PMCID: PMC9264589 DOI: 10.1186/s12891-022-05604-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 06/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Pediatric spinal fusion may be associated with significant intraoperative blood loss, leading to complications from transfusion, hypoperfusion and coagulopathy. One emerging strategy to mediate these risks is by utilization of the anti-fibrinolytic agent tranexamic acid (TXA). However, concerns regarding potential adverse reactions, specifically postoperative seizures and thrombotic events, still exist. To assess these risks, we examined the perioperative morbidity of TXA use in a large national database. Methods Retrospective data from pediatric patients (age 18 years or younger), discharged between January 2013 to December 2015, who underwent primary or revision posterior spinal fusions, was collected from the Premier Perspective database (Premier, Charlotte, NC). Patients were stratified by TXA use and records were assessed for complications of new onset seizures, strokes, pulmonary embolisms (PE) or deep vein thromboses (DVT) occurring during the perioperative period. Results In this cohort of 2,633 pediatric patients undergoing posterior spinal fusions, most often to treat adolescent idiopathic scoliosis, 15% received TXA. Overall, adverse events were rare in this patient population. The incidence of seizure, stoke, PE, or DVT in the control group was 0.54% (95% CI, 0.31% to 0.94%) and not significantly different from the TXA group. There was no significant difference in the incidence of DVTs, and no incidences of stroke in either group. There were no new-onset seizures or PEs in patients who received TXA. Conclusions The use of TXA was not associated with an increased risk of adverse events including seizure, stroke, PE, and DVT. Our findings support the safety of TXA use in pediatric patients undergoing spinal fusion surgery.
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Affiliation(s)
- Iryna Ivasyk
- Weill Cornell Medical College, New York, NY, USA
| | | | - Catherine Jordan
- Department of Psychology, Thompson Rivers University, Kamloops, BC, Canada
| | - Matthew T Geiselmann
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York, USA
| | - Peter S Chang
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
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22
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Alfitian J, Scheyerer MJ, Rohde A, Schick V, Kammerer T, Schier R. Omission of tranexamic acid does not increase the amount of perioperative blood transfusions in patients undergoing one-level spinal fusion surgery: a retrospective propensity score-matched noninferiority study. Arch Orthop Trauma Surg 2022; 143:2943-2950. [PMID: 35708870 DOI: 10.1007/s00402-022-04494-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 05/18/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Application of tranexamic acid (TXA) in spine surgery is very frequent even without signs of hyperfibrinolysis, although its beneficial blood-saving effects are offset by harmful adverse events such as thromboembolic incidents. Thus, we investigated whether in relatively less invasive spinal procedures such as one-level posterior spinal fusion, omission of TXA affects the requirement for blood transfusions. METHODS We conducted a retrospective propensity score-matched noninferiority study with 212 patients who underwent one-level posterior spine fusion and who were stratified according to whether they received TXA intraoperatively at our tertiary care center. The primary endpoint was the volume of transfused packed red cells. Testing for noninferiority or equivalence was performed by two one-sided testing procedure (TOST) with a priori defined noninferiority margins ([Formula: see text]). RESULTS After propensity score matching a total of five patients (11.6%) treated with TXA were transfused compared with five patients (11.6%) who did not receive TXA. The majority of patients (51.2%) had a risk-increasing condition. The risk difference (no TXA-TXA) of intraoperative transfusion was - 4.7% (CI 90% - 13.62 to 4.32%), and omitting TXA was noninferior ([Formula: see text] = [Formula: see text] 10%). The mean intergroup difference in transfused volume (no TXA-TXA) was - 23.26 ml intraoperatively (CI 90% - 69.34 to 22.83 ml) and - 46.51 ml overall (CI 90% - 181.12 to 88.1 ml), respectively, suggesting equivalence of TXA omission ([Formula: see text] = [Formula: see text] 300 ml). The hemoglobin decline between both groups was also equivalent (with [Formula: see text] = [Formula: see text] 1 g/dl) both on the first postoperative day ([Formula: see text] Hb = 0.02 g/dl, CI 90% - 0.53 to 0.56 g/dl) and at discharge ([Formula: see text] Hb = - 0.29 g/dl, CI 90% - 0.89 to 0.31 g/dl). CONCLUSION We demonstrated that requirement of transfusion is rare among one-level fusion surgery and the omission of TXA is noninferior with regard to blood transfusion in high-risk patients undergoing this procedure. Therefore, the prophylactic use of TXA cannot be recommended here, suggesting to focus on alternative blood conservation strategies, if necessary.
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Affiliation(s)
- Jonas Alfitian
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Max Joseph Scheyerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedics and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Axel Rohde
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedics and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Volker Schick
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
| | - Tobias Kammerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
| | - Robert Schier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
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23
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Oyama R, Setsu N, Matsumoto Y, Endo M, Fujiwara T, Iida K, Nabeshima A, Nakashima Y. Efficacy and safety of tranexamic acid in patients undergoing surgery for bone and soft tissue tumors: a propensity score matching analysis. Jpn J Clin Oncol 2022; 52:1029-1038. [DOI: 10.1093/jjco/hyac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/23/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
The aim of this study was to investigate the efficacy and safety of tranexamic acid in patients undergoing surgery for bone and soft tissue tumors.
Methods
Data were retrospectively collected from 454 consecutive patients with bone and soft tissue tumors who underwent open biopsy, marginal resection, curettage or wide resection between January 2017 and December 2018. We performed propensity score matching of patients who received tranexamic acid with those who did not. The primary outcome variables were intra-operative, peri-operative and estimated blood loss (IBL, PBL and EBL, respectively).
Results
Tranexamic acid (+) and tranexamic acid (−) groups were defined according to whether patients received tranexamic acid or not. Among the 454 patients, open biopsy was performed in 102, marginal resection in 175, curettage in 54 and wide resection in 123. Intra-operative blood loss was significantly lower in the tranexamic acid (+) group than in the tranexamic acid (−) group for both marginal and wide resection (marginal resection: 17.3 vs. 70.3 g, respectively, P = 0.045; wide resection: 128.8 vs. 273.1 g, respectively, P = 0.023). Peri-operative blood loss and estimated blood loss were also significantly lower in the tranexamic acid (+) group for wide resection (peri-operative blood loss: 341.5 vs. 686.5 g, respectively, P = 0.0039; estimated blood loss: 320.7 vs. 550.6 ml, respectively, P = 0.030). No venous thromboembolism occurred in either group.
Conclusion
This study suggests that TXA administration safely and effectively reduces blood loss, in particular for wide resection, with no increase in the rate of adverse events.
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Affiliation(s)
- Ryunosuke Oyama
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nokitaka Setsu
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Orthopaedic Surgery, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Yoshihiro Matsumoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Makoto Endo
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshifumi Fujiwara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keiichiro Iida
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akira Nabeshima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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24
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Haddad AF, Ames CP, Safaee M, Deviren V, Lau D. The Effect of Systemic Tranexamic Acid on Hypercoagulable Complications and Perioperative Outcomes Following Three-Column Osteotomy for Adult Spinal Deformity. Global Spine J 2022; 12:423-431. [PMID: 32969252 PMCID: PMC9121167 DOI: 10.1177/2192568220953812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Thoracolumbar 3-column osteotomy (3CO) is a powerful technique for correction of rigid adult spinal deformity (ASD). However, it can be associated with high-volume blood loss. This study seeks to investigate the efficacy and safety of tranexamic acid (TXA) in 3CO ASD patients. METHODS ASD patients who underwent 3CO from 2006 to 2019 were retrospectively reviewed. Outcomes were compared between TXA and non-TXA patients, and TXA doses. RESULTS A total of 365 ASD patients were included: 181 TXA and 184 non-TXA. The mean age was 64.6 years and 60.5% were female. Operative time was shorter in the TXA group (295.6 vs 320.2 minutes, P < .001). However, TXA was not associated with shorter operative time (β = -6.5 minutes, 95% CI -29.0 to 15.9, P = .567) after accounting for surgeon experience. There was no difference in blood loss (2020.2 vs 1914.1 mL, P = .437) between groups. Overall complications (37.0% vs 33.2%, P = .439), including hypercoagulable (2.2% vs 3.8%, P = .373) and cardiac (13.3% vs 7.1%, P = .050) complications were similar between groups. TXA was not independently associated with blood loss or TXA-related complications. Both groups had comparable intensive care unit (2.5 vs 2.0 days, P = .060) and hospital (8.9 vs 8.2 days, P = .190) stays. There were no differences in outcomes between TXA dosing subgroups. CONCLUSIONS Systemic TXA use during 3CO for ASD surgery was not associated with decreased blood loss. TXA patients had shorter operative times, but this was driven mainly by surgeon experience on multivariate analysis. Routine use of TXA is safe and does not increase the incidence of hypercoagulable complications even at high doses.
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Affiliation(s)
| | | | - Michael Safaee
- University of California, San Francisco, San Francisco, CA, USA
| | - Vedat Deviren
- University of California, San Francisco, San Francisco, CA, USA
| | - Darryl Lau
- University of California, San Francisco, San Francisco, CA, USA
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25
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Brown NJ, Wilson B, Ong V, Gendreau JL, Yang CY, Himstead AS, Shahrestani S, Shlobin NA, Reardon T, Choi EH, Birkenbeuel J, Cohn SJ, Sahyouni R, Yang I. Use of Tranexamic Acid for Elective Resection of Intracranial Neoplasms: A Systematic Review. World Neurosurg 2022; 160:e209-e219. [PMID: 34995825 DOI: 10.1016/j.wneu.2021.12.117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND As an established antifibrinolytic agent, tranexamic acid (TXA) has garnered widespread use during surgery to limit intraoperative blood loss. In the field of neurosurgery, TXA is often introduced in cases of traumatic brain injury or elective spine surgeries; however, its role during elective cranial surgeries is not well established. We report a systematic review of the use of TXA in elective surgical resection of intracranial neoplasms. METHODS We performed this systematic review following PRISMA guidelines to identify studies investigating the use of TXA in elective neurosurgical resection of intracranial neoplasms. Variables extracted included patient demographics, surgical indications, type of surgery performed, TXA dose and route of administration, operative duration, blood loss, transfusion rate, postoperative hemoglobin level, and complications. RESULTS After careful screening, 4 articles (consisting of 682 patients) met our inclusion/exclusion criteria. The studies included 2 prospective cohort studies, 1 retrospective cohort study, and 1 case series. A χ2 test of pooled data demonstrated that patients administered TXA had a significantly decreased need for blood transfusions during surgery (odds ratio, 0.6273; 95% confidence interval, 0.4254-0.9251; P = 0.018). Mean total blood loss was 821.9 mL in the TXA group and 1099.0 mL in the control group across the studies. There was no significant difference in postoperative hemoglobin levels, with a mean of 11.4 g/dL in both the TXA and control groups. CONCLUSIONS These results support the use of intraoperative TXA in tumor resection. However, its role in tumor resection has been less well investigated compared with its use in other areas of neurosurgery.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Bayard Wilson
- Department of Neurological Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Vera Ong
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Julian L Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA.
| | - Chen Yi Yang
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Alexander S Himstead
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Shane Shahrestani
- Keck School of Medicine of USC, Los Angeles, California, USA; Medical Scientist Training Program, California Institute of Technology, Pasadena, California, USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, Kentucky, USA
| | - Elliot H Choi
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Jack Birkenbeuel
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Sebastian J Cohn
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ronald Sahyouni
- Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
| | - Isaac Yang
- Department of Neurological Surgery, University of California Los Angeles, Los Angeles, California, USA
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26
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Li Y, Zhang Y, Fang X. Acute normovolemic hemodilution in combination with tranexamic acid is an effective strategy for blood management in lumbar spinal fusion surgery. J Orthop Surg Res 2022; 17:71. [PMID: 35123513 PMCID: PMC8817589 DOI: 10.1186/s13018-022-02950-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/21/2022] [Indexed: 11/11/2022] Open
Abstract
Background The retrospective study was designed to compare the effectiveness and safety of acute normovolemic hemodilution (ANH), tranexamic Acid (TXA), and a combination of ANH and TXA in lumbar spinal fusion surgery. Methods Data of 120 patients underwent multi-level posterior spinal fusion for treating degenerative lumbar disease between June 2013 and December 2017 was collected, retrospectively. Four treatment strategies were enrolled, including ANH, TXA, a combination of ANH and TXA, and without any patient blood management. Intraoperative blood loss, hemoglobin and PCV at the end of surgery and at the postoperative first day, and postoperative drain collection, and intraoperative and postoperative transfusion and rate of transfusion were also collected. Results Intraoperative blood loss and postoperative drain collection of the TXA group, ANH combined with TXA group were statistically lower than those in the control group and ANH group (P < 0.05). Intraoperative and postoperative transfusion amount and rate of intra-operative allogenic transfusion of the ANH group, TXA group, and ANH combined with TXA group were statistically lower than those of the control group (P < 0.05). Hemoglobin and PCV at postoperative the first day in the ANH group, TXA group, and ANH combined with TXA group were significant higher than those in the control group (P < 0.05). The combination of TXA and ANH group achieved the lowest intraoperative blood loss, postoperative drain collection and allogenic transfusion rate. Conclusion A combination of TXA and ANH might be an effective strategy for reducing the rate of transfusion and blood loss in patients underwent lumbar spinal fusion surgery.
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27
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Oral Is as Effective as Intravenous Tranexamic Acid at Reducing Blood Loss in Thoracolumbar Spinal Fusions: A Prospective Randomized Trial. Spine (Phila Pa 1976) 2022; 47:91-98. [PMID: 34224510 DOI: 10.1097/brs.0000000000004157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective randomized trial at a university affiliated tertiary medical center between February 2017 and March 2020. OBJECTIVE The aim of this study was to compare perioperative blood loss in patients undergoing elective posterior thoracolumbar fusion who were treated with IV versus PO TXA. SUMMARY OF BACKGROUND DATA The use of antifibrinolytic agents such as tranexamic acid (TXA) to decrease operative blood loss and allogenic blood transfusions is well documented in the literature. Although evidence supports the use of intravenous (IV) and topical formulations of TXA in spine surgery, the use of oral (PO) TXA has not been studied. METHODS A total of 261 patients undergoing thoracolumbar fusion were randomized to receive 1.95 g of PO TXA 2 hours preoperatively or 2 g IV TXA (1 g before incision and 1 g before wound closure) intraoperatively. The sample was further stratified into three categories based on number of levels fused (one-to two-level fusions, three to five, and more than five). The primary outcome was the reduction of hemoglobin. Secondary outcomes included calculated blood loss, drain output, postoperative transfusion, complications, and length of hospital stay. Equivalence analysis was performed with a two one-sided test. RESULTS One hundred thirty-seven patients received IV and 124 received PO TXA. The average age was 62 ± 13 years (mean ± SD), including 141 females and 120 males. Revision cases comprised of 67% of the total sample. Patient demographic factors were similar between groups except for weight, BMI, and preoperative platelet count. The mean reduction of hemoglobin was similar between IV and PO groups (3.56 vs. 3.28 g/dL, respectively; P = 0.002, equivalence). IV TXA group had a higher transfusion rate compared to PO TXA group (22 patients [19%] vs. 12 patients [10%]; P = 0.03). In addition, IV group had longer length of stay (LOS) than PO group (4.4 vs. 3.7 days; P = 0.02). CONCLUSION Patients treated with IV and PO TXA experienced the same perioperative blood loss after small and large spinal fusions. In subgroup analysis, the intermediate (three to five level) spinal fusions had less blood loss with PO TXA than IV TXA. Given its lower cost, PO TXA represents a superior alternative to IV TXA in patients undergoing elective posterior thoracolumbar fusion and may improve health care cost-efficiency in the studied population.Level of Evidence: 1.
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28
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Brown NJ, Choi EH, Gendreau JL, Ong V, Himstead A, Lien BV, Shahrestani S, Ransom SC, Tran K, Tafreshi AR, Sahyouni R, Chan A, Oh MY. Association of tranexamic acid with decreased blood loss in patients undergoing laminectomy and fusion with posterior instrumentation: a systematic review and meta-analysis. J Neurosurg Spine 2021; 36:686-693. [PMID: 34740174 DOI: 10.3171/2021.7.spine202217] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tranexamic acid (TXA) is an antifibrinolytic agent associated with reduced blood loss and mortality in a wide range of procedures, including spine surgery, traumatic brain injury, and craniosynostosis. Despite this wide use, the safety and efficacy of TXA in spine surgery has been considered controversial due to a relative scarcity of literature and lack of statistical power in reported studies. However, if TXA can be shown to reduce blood loss in laminectomy with fusion and posterior instrumentation, more surgeons may include it in their armamentarium. The authors aimed to conduct an up-to-date systematic review and meta-analysis of the efficacy of TXA in reducing blood loss in laminectomy and fusion with posterior instrumentation. METHODS A systematic review and meta-analysis, abiding by PRISMA guidelines, was performed by searching the databases of PubMed, Web of Science, and Cochrane. These platforms were queried for all studies reporting the use of TXA in laminectomy and fusion with posterior instrumentation. Variables retrieved included patient demographics, surgical indications, involved spinal levels, type of laminectomy performed, TXA administration dose, TXA route of administration, operative duration, blood loss, blood transfusion rate, postoperative hemoglobin level, and perioperative complications. Heterogeneity across studies was evaluated using a chi-square test, Cochran's Q test, and I2 test performed with R statistical programming software. RESULTS A total of 7 articles were included in the qualitative study, while 6 articles featuring 411 patients underwent statistical analysis. The most common route of administration for TXA was intravenous with 15 mg/kg administered preoperatively. After the beginning of surgery, TXA administration patterns were varied among studies. Blood transfusions were increased in non-TXA cohorts compared to TXA cohorts. Patients administered TXA demonstrated a significant reduction in blood loss (mean difference -218.44 mL; 95% CI -379.34 to -57.53; p = 0.018). TXA administration was not associated with statistically significant reductions in operative durations. There were no adverse events reported in either the TXA or non-TXA patient cohorts. CONCLUSIONS TXA can significantly reduce perioperative blood loss in cervical, thoracic, and lumbar laminectomy and fusion procedures, while demonstrating a minimal complication profile.
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Affiliation(s)
- Nolan J Brown
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Elliot H Choi
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Julian L Gendreau
- 3Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Vera Ong
- 4Department of Neurosurgery, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii
| | - Alexander Himstead
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Brian V Lien
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Shane Shahrestani
- 5Keck School of Medicine of University of Southern California, Los Angeles, California.,6Medical Scientist Training Program, California Institute of Technology, Pasadena, California
| | - Seth C Ransom
- 7College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Katelynn Tran
- 8University of Southern California, Los Angeles, California
| | - Ali R Tafreshi
- 9Department of Neurological Surgery, Geisinger Health System, Danville, Pennsylvania; and
| | - Ronald Sahyouni
- 10Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Alvin Chan
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
| | - Michael Y Oh
- 1Department of Neurological Surgery, University of California, Irvine, Orange, California
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29
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Chou SH, Lin SY, Wu MH, Tien YC, Jong YJ, Liang WC, Lu YM, Shih CL, Lu CC. Intravenous Tranexamic Acid Reduces Blood Loss and Transfusion Volume in Scoliosis Surgery for Spinal Muscular Atrophy: Results of a 20-Year Retrospective Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18199959. [PMID: 34639259 PMCID: PMC8507662 DOI: 10.3390/ijerph18199959] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/17/2021] [Accepted: 09/19/2021] [Indexed: 11/16/2022]
Abstract
Intravenous tranexamic acid (TXA) has been administered to reduce intraoperative blood loss in scoliosis surgery. However, the therapeutic effect of TXA on spinal muscular atrophy (SMA) scoliosis surgery is not well demonstrated. Therefore, this study aimed to assess the efficacy of intravenous TXA in SMA scoliosis surgery. From December 1993 to August 2020, 30 SMA patients who underwent scoliosis surgery (posterior fusion with fusion level of thoracic second or third to pelvis) were retrospectively enrolled and divided into the TXA group and non-TXA (control) group, with 15 patients in each group. Survey parameters were the amount of blood loss, blood transfusion, crystalloid transfusion volume, intubation time, and associated pulmonary complications (including pneumonia, pulmonary edema, and pulmonary atelectasis). The TXA group had significantly lesser blood loss than the control group (p = 0.011). Compared with the control group, the TXA group had significantly lower blood transfusion (p < 0.001), crystalloid volume (p = 0.041), and total transfusion volume (p = 0.005). In addition, the TXA group had fewer postoperative pulmonary complications, and patients with pulmonary complications were associated with a higher relative crystalloid volume and relative total transfusion volume (p = 0.003 and 0.022, respectively). In conclusion, TXA can be effective in reducing intraoperative blood loss and crystalloid fluid transfusions during scoliosis surgery in SMA patients, which may aid in reducing postoperative pulmonary complications.
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Affiliation(s)
- Shih-Hsiang Chou
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (S.-H.C.); (S.-Y.L.); (Y.-C.T.); (Y.-M.L.)
- Orthopaedic Research Centre, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Sung-Yen Lin
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (S.-H.C.); (S.-Y.L.); (Y.-C.T.); (Y.-M.L.)
- Orthopaedic Research Centre, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Orthopaedics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Meng-Huang Wu
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 11031, Taiwan;
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Yin-Chun Tien
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (S.-H.C.); (S.-Y.L.); (Y.-C.T.); (Y.-M.L.)
- Department of Orthopaedics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Yuh-Jyh Jong
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (Y.-J.J.); (W.-C.L.)
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Wen-Chen Liang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (Y.-J.J.); (W.-C.L.)
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Yen-Mou Lu
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (S.-H.C.); (S.-Y.L.); (Y.-C.T.); (Y.-M.L.)
- Department of Orthopaedics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Chia-Lung Shih
- Clinical Medicine Research Center, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City 600, Taiwan;
| | - Cheng-Chang Lu
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan; (S.-H.C.); (S.-Y.L.); (Y.-C.T.); (Y.-M.L.)
- Orthopaedic Research Centre, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Orthopaedics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Orthopaedics, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan
- Correspondence:
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K S A, Kumar P, Subair M, Sharma RK. Effect of single dose intravenous tranexamic acid on blood loss in tangential excision of burn wounds - A double blind randomised controlled trial. Burns 2021; 48:1311-1318. [PMID: 34952736 DOI: 10.1016/j.burns.2021.08.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 08/21/2021] [Accepted: 08/26/2021] [Indexed: 11/02/2022]
Abstract
INTRODUCTION This study was carried out to evaluate role of intravenous tranexamic acid (TXA) in reducing blood loss during tangential excision of burns. METHODS This was a single center, prospective double-blinded parallel arm superiority randomized placebo-controlled trial. Patients (15-55 years) with deep dermal thermal burns <30% undergoing tangential excision were randomly assigned (1:1) to TXA and placebo groups. Patients in TXA and placebo groups received injection TXA 15 mg/kg and 10 ml saline respectively, 10 min preoperatively. Primary outcome was volume of blood loss per square centimeter area of burn excised. Secondary outcomes were total volume of blood loss, postoperative hemoglobin, intraoperative fluid requirement, blood transfusion, graft take and length of hospitalization (LOH). RESULTS Thirty patients were included. Both groups were comparable in terms of Body Mass Index (BMI) preoperative hemoglobin, area of burn excised, duration of surgery and the intraoperative temperature. The average blood loss per square centimeter burn area excised was found to be significantly lower in TXA when compared to placebo group (mean difference: 0.28 ± 0.025 ml/cm2; p = 0.000). The total volume of blood loss was lower in TXA group (258.7 ± 124.10 ml vs 388.1 ± 173.9 ml; p = 0.07). None of the patients required transfusion. The requirement of intra-operative fluids was similar between the two groups (crystalloids: p = 0.236; colloids: p = 0.238). Postoperative hemoglobin, length of hospitalization and graft-take were comparable between the two groups. CONCLUSION TXA reduced blood loss per unit burn area of tangential excision in <30%TBSA burn, however, we found no significant effect on postoperative Hb and transfusion.
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Affiliation(s)
- Ajai K S
- Department of Plastic & Reconstructive Surgery, PGIMER, Chandigarh, India.
| | - Parmod Kumar
- Department of Plastic & Reconstructive Surgery, PGIMER, Chandigarh, India.
| | - Mohsina Subair
- Department of Plastic & Reconstructive Surgery, PGIMER, Chandigarh, India.
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Brouwer AJ, Kempink DR, de Witte PB. Tranexamic acid reduces blood loss in paediatric proximal femoral and/or pelvic osteotomies. J Child Orthop 2021; 15:241-247. [PMID: 34211600 PMCID: PMC8223094 DOI: 10.1302/1863-2548.15.200249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/23/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Proximal femoral and/or pelvic osteotomies (PFPO) are associated with significant blood loss, which can be harmful, especially in paediatric patients. Therefore, considering methods to reduce blood loss is important. The purpose of this study was to examine the efficacy of tranexamic acid (TXA) in reducing intraoperative estimated blood loss (EBL) in paediatric patients undergoing a PFPO. METHODS Paediatric patients who had a PFPO between 2014 and 2019 were retrospectively reviewed. Outcome measures included patient demographics, TXA use (none, preoperative and/or intraoperative bolus, pump), EBL, transfusion rate and thromboembolic complications. Univariate and multivariate analyses were performed to assess associations between investigated outcome measures and EBL. RESULTS A total of 340 PFPO (263 patients) were included. Mean age at surgery was 8.0 years (sd 4.3). In all, 269 patients received no TXA, 20 had a preoperative bolus, 43 had an intraoperative bolus and eight patients had other TXA regimes (preoperative and intraoperative bolus or pump). Overall, mean blood loss was 211 ml (sd 163). Multivariate analysis showed significant associations between higher EBL and higher age at surgery, male sex, higher body mass index and longer procedure time. There was a significant association between lower EBL and a preoperative TXA bolus: 66 ml (33%) less EBL compared with patients without TXA (95% confidence interval -129 to -4; p = 0.04). No thromboembolic complications were reported in any of the studied patients. CONCLUSION Preoperative TXA administration is associated with a decreased EBL in PFPO. No thromboembolic events were reported. Administering TXA preoperatively appears to be effective in paediatric patients undergoing a PFPO. LEVEL OF EVIDENCE Level III - retrospective comparative study.
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Affiliation(s)
- Anne J. Brouwer
- Faculty of Medicine, Erasmus University Rotterdam, Erasmus MC, University Medical Center Rotterdam, The Netherlands
- Department of Pediatric Orthopaedics, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, The Netherlands
| | - Dagmar R.J. Kempink
- Department of Pediatric Orthopaedics, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, The Netherlands
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieter Bas de Witte
- Department of Pediatric Orthopaedics, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, The Netherlands
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
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Pekrul I, Schachtner T, Zwißler B, Möhnle P. [Tranexamic acid for bleeding prophylaxis in orthopedic surgery and trauma-standard or customized therapy?]. Anaesthesist 2021; 70:515-521. [PMID: 33620508 PMCID: PMC8190014 DOI: 10.1007/s00101-021-00928-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 11/23/2022]
Abstract
The use of tranexamic acid (TXA) is established in the treatment of bleeding, especially of bleeding due to hyperfibrinolysis. In recent years the prophylactic use of TXA in trauma and orthopedic surgery has increased leading to open questions regarding potentially associated risks and a possible classification as off label use. The available literature provides a sound basis for the recommendation that TXA can be used in these indications provided that an individual risk assessment is done in patients with increased risks for thromboembolic complications. Although the prophylactic use of TXA in orthopedic surgery and trauma is not explicitly listed in the product characteristics, it should not be regarded as an off label use.
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Affiliation(s)
- Isabell Pekrul
- Klinik für Anaesthesiologie, Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Universität München (LMU), Marchioninistr. 15, 81377, München, Deutschland
| | - Thomas Schachtner
- Anästhesie und Intensivmedizin, Schön Klinik München Harlaching, München, Deutschland
| | - Bernhard Zwißler
- Klinik für Anaesthesiologie, Universität München (LMU), München, Deutschland
| | - Patrick Möhnle
- Klinik für Anaesthesiologie, Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Universität München (LMU), Marchioninistr. 15, 81377, München, Deutschland.
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Hanada K, Ahmad A, Shadi H, Wajdi A, Haitham S, Wesam K, Lamees A, Qamar M, Rami A. Castigating intraoperative bleeding: Tranexamic acid, a new ally. Asian J Neurosurg 2021; 16:51-55. [PMID: 34211866 PMCID: PMC8202383 DOI: 10.4103/ajns.ajns_339_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/28/2020] [Accepted: 10/15/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction: The field of instrumented spinal procedures is associated with substantial blood volume losses, which is one of the major hazards we encounter; this would lead to a greater need for blood products transfusions. The frequent use of these products can have negative consequences due to body fluid shifting, and donor-host rejection. Thus, it has become mandatory to establish strategies to maintain blood volume and minimize losses. Several strategies have been approved to control the disproportionate blood loss. Objective: This study aims to assess the effectiveness of tranexamic acid in reducing intraoperative bleeding during our spine instrumented surgeries, while addressing complications associated. Methods: In this retrospective analysis was steered of 153- consecutive patients treated in the neurosurgical- spine unit of King Hussein hospital, King Hussein Medical Center (KHMC), between April 2017 to January 2020, patients who underwent instrumented surgery for different spinal pathologies at our institute were reviewed. Results: During the analysis period, 153-patients who underwent interbody fusion, were allocated into two groups. The mean instrumented segments were 2.8 level (range 1-5 levels). The demographical data of patients of both groups analyzed. The mean span of operating time was (212.74 ± 41.85 min) for group I, while for the control group mean length was (208.09min ±42.03). Study showed that the mean drop in the hemoglobin concentration postoperatively was statistically significant comparing the two groups. Analysis of blood volume in suction container showed that group I had: 470 ml ±153.06 ml; while in control group volume was: 1560 ml ± 567.59 ml, which showed significant difference (p = 0.002). Comparing the drainage volumes at 12 hours postoperatively displayed no statistically significant differences (p = 0.69) concerning the two groups. Minor adverse effects allied with the tranexamic acid administration. Conclusions: In summary, perioperative bleeding deemed one of the most important threat for patients. Tranexamic acid is proved excellent in controlling perioperative bleeding, harboring few contraindications. Future large studies are still needed to elaborate on unanswered issues.
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Affiliation(s)
- Krashan Hanada
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Alhasan Ahmad
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Hammadeen Shadi
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Alnajada Wajdi
- Department of Radiation Oncology, Queen Alia Military Hospital, Royal Medical Services, Amman, Jordan
| | - Saraireh Haitham
- Department of Radiation Oncology, Queen Alia Military Hospital, Royal Medical Services, Amman, Jordan
| | - Khresat Wesam
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Arabiyat Lamees
- Department of Plastic Surgery, Farah Medical Center, Royal Medical Services, Amman, Jordan
| | - Malabeh Qamar
- Department of Radiology, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Alqroom Rami
- Department of Neurosurgery, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
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Tamer TM, Sabet MM, Omer AM, Abbas E, Eid AI, Mohy-Eldin MS, Hassan MA. Hemostatic and antibacterial PVA/Kaolin composite sponges loaded with penicillin-streptomycin for wound dressing applications. Sci Rep 2021; 11:3428. [PMID: 33564036 PMCID: PMC7873205 DOI: 10.1038/s41598-021-82963-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 01/27/2021] [Indexed: 12/13/2022] Open
Abstract
Hemorrhage is the major hindrance over the wound healing, which triggers microbial infections and might provoke traumatic death. Herein, new hemostatic and antibacterial PVA/Kaolin composite sponges were crosslinked using a freeze-thawing approach and boosted by penicillin–streptomycin (Pen-Strep). Physicochemical characteristics of developed membranes were analyzed adopting Fourier transformed infrared spectroscopy (FT-IR), scanning electron microscopy (SEM), a thermal gravimetric analyzer (TGA), and differential scanning calorimetry (DSC). Furthermore, the impacts of kaolin concentrations on porosity, swelling behavior, gel fraction, and degradation of the membranes were investigated. SEM analyses revealed a spongy-like structure of hydrogels associated with high dispersion of kaolin inside PVA matrix. The thermal characteristics of PVA/Kaolin were significantly ameliorated compared to the prime PVA. Moreover, the results exhibited significant variations of swelling performance, surface roughness and pore capacity due to the alterations of kaolin contents. Besides, the adhesive strength ability was manifestly enhanced for PVA-K0.1 sponge. Biomedical evaluations including antibacterial activity, blood clotting index and thrombogenicity of the membranes were studied. The contact of PVA/Kaolin to blood revealed notable augmentation in blood clotting. Furthermore, the incorporation of kaolin into PVA presented mild diminution in antibacterial activities. Moreover, PVA/Kaolin composites illustrated no cellular toxicity towards fibroblast cells. These remarkable features substantiate that the PVA-K0.1 sponge could be applied as a multifunctional wound dressing.
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Affiliation(s)
- Tamer M Tamer
- Polymer Materials Research Department, Advanced Technology and New Materials Research Institute (ATNMRI), City of Scientific Research and Technological Applications (SRTA-City), New Borg El-Arab City, P.O. Box: 21934, Alexandria, Egypt.
| | - Maysa M Sabet
- Polymer Materials Research Department, Advanced Technology and New Materials Research Institute (ATNMRI), City of Scientific Research and Technological Applications (SRTA-City), New Borg El-Arab City, P.O. Box: 21934, Alexandria, Egypt
| | - Ahmed M Omer
- Polymer Materials Research Department, Advanced Technology and New Materials Research Institute (ATNMRI), City of Scientific Research and Technological Applications (SRTA-City), New Borg El-Arab City, P.O. Box: 21934, Alexandria, Egypt
| | - Eman Abbas
- Zoology Department, Faculty of Science, Alexandria University, Alexandria, Egypt
| | - Alaa I Eid
- Advanced Materials Division, Composites Department, Central Metallurgical Research Institute (CMRDI), Eltebbin, Helwan, 12422, Cairo, Egypt
| | - Mohamed S Mohy-Eldin
- Polymer Materials Research Department, Advanced Technology and New Materials Research Institute (ATNMRI), City of Scientific Research and Technological Applications (SRTA-City), New Borg El-Arab City, P.O. Box: 21934, Alexandria, Egypt
| | - Mohamed A Hassan
- Protein Research Department, Genetic Engineering and Biotechnology Research Institute (GEBRI), City of Scientific Research and Technological Applications (SRTA-City), New Borg El-Arab City, P.O. Box: 21934, Alexandria, Egypt.
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Ho CH, Wong RNM. Effectiveness of tranexamic acid in reducing blood loss in cervical laminoplasty: A retrospective observational study. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491720941872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Tranexamic acid (TXA) has been proved effective in reducing perioperative blood loss in patients undergoing orthopedic operations. However, given the heterogeneity in the diagnoses and spinal operations, there are only limited studies comparing patients with uniform diagnoses and procedures performed. Methods: A comparative observational control study was performed on 62 patients with cervical myelopathy. They were divided into control (32) and TXA (30) groups according to whether they had received TXA before and during surgery. Cervical laminoplasty from C3 to C6/7 was performed for all patients using a consistent procedure. Preoperative and postoperative hematological data and perioperative blood loss were compared. Results: There were no statistically significant differences between the two groups in terms of age, gender, body mass index, and operating time. The TXA group had significantly less intraoperative (310 ± 215 ml vs. 144 ± 90 ml, p < 0.05) and postoperative blood loss than the control group (150 ± 50 ml vs. 249 ± 94 ml, p < 0.01). The drop of hemoglobin (Hb) level in the TXA group was also significantly lower (0.5 ± 0.42 g/dl vs. 2.1 ± 1.03 g/dl, p < 0.01). No thromboembolic complications found. Conclusion: TXA significantly reduced perioperative blood loss and reduced drop of postoperative Hb level in cervical laminoplasty.
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Affiliation(s)
- Chi-Hei Ho
- Department of Orthopaedics and Traumatology, United Christian Hospital, Kwun Tong, Hong Kong
| | - Raymond Nang-Man Wong
- Department of Orthopaedics and Traumatology, United Christian Hospital, Kwun Tong, Hong Kong
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Johns WL, Walley KC, Seedat R, Jackson B, Boukhemis K, Gonzalez T. Tranexamic Acid Use in Foot and Ankle Surgery. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420975419. [PMID: 35097417 PMCID: PMC8564923 DOI: 10.1177/2473011420975419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: There is a potential role for tranexamic acid (TXA) use in foot and ankle procedures; however, the benefits of this intervention have not been fully elucidated. The purpose of this study was to explore the safety, outcomes, and medical complication profile of the use of intravenous TXA in patients undergoing foot and ankle surgery. Methods: A prospective study with retrospective review of 241 patients undergoing elective and traumatic foot and ankle procedures was performed. One gram of intravenous (IV) TXA was administered prior to incision. Patients were followed and evaluated for medical comorbidities, intraoperative blood loss, wound complication, superficial and deep infections, hematoma formation, medical complications, 30-day hospital readmission rate, and return visits to the emergency department or urgent care setting prior to first postoperative visit. Descriptive statistics were used for subgroup analysis. Mean postoperative follow-up was 4.5 months. Results: Estimated blood loss in all cases was less than 20 mL. There was 1 case of superficial cellulitis (1/241, 0.4%), 1 deep infection after Achilles tendon repair (1/241, 0.4%), 4 cases of delayed wound healing (4/241, 1.6%), 1 instance of deep vein thrombosis (1/241, 0.4%), and 2 cases of postoperative pulmonary embolism (2/241, 0.8%). There were no instances of postoperative hematoma formation. There were no additional recorded thromboembolic events. There were no adverse drug reactions. There were no 30-day hospital readmissions or return visits to the emergency department or urgent care setting before the first postoperative visit. In a subgroup analysis, there was no significant difference in wound complications or infections between nondiabetics and diabetics (P > .05) and traumatic and nontraumatic cases (P > .05). Conclusions: The use of IV TXA in foot and ankle surgeries was associated with low risk of wound complications, infections, hematoma formation, thromboembolic events, and overall complication rates with minimal side effect profile. Perioperative tranexamic acid use may prove to be beneficial in foot and ankle surgery patients but especially in higher-risk patients such as those with diabetes, trauma, and those that are immunocompromised. Level of Evidence: Level IV, case series.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kempland C Walley
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Raees Seedat
- Virginia Commonwealth University, School of Medicine, Richmond, VA, USA
| | - Benjamin Jackson
- University of South Carolina, School of Medicine, Columbia, SC, USA
| | | | - Tyler Gonzalez
- University of South Carolina, School of Medicine, Columbia, SC, USA
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Abstract
PURPOSE OF REVIEW Bleeding at the time of benign gynecologic surgery, as well as from benign gynecologic conditions, is a major source of morbidity for many women. Few nonhormonal medical options exist for the treatment of heavy menstrual bleeding, and to reduce surgical bleeding during major gynecologic surgery. Interest in Tranexamic acid (TXA) as a means to reduce surgical blood loss has been growing across many surgical specialties. This review focuses on applications for TXA as a means to reduce heavy menstrual bleeding (HMB) as well as to reduce surgical bleeding during benign gynecologic surgery. RECENT FINDINGS Tranexamic acid is an effective treatment to reduce the volume of bleeding during menstruation. Tranexamic acid was found to be superior to both placebo and oral progestins, and as good as combined oral contraceptives at reducing menstrual blood volume. Tranexamic acid has also been show to reduce the volume of bleeding during abdominal myomectomy as well as hysterectomy. There is a major need for prospective studies evaluating the utility of TXA for reducing blood loss during benign gynecologic surgery. SUMMARY Tranexamic acid has been found to be an excellent affordable nonhormonal treatment option for women with HMB and should be considered during major gynecologic surgery.
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Combined use of tranexamic acid and rivaroxaban in posterior lumbar interbody fusion safely reduces blood loss and transfusion rates without increasing the risk of thrombosis—a prospective, stratified, randomized, controlled trial. INTERNATIONAL ORTHOPAEDICS 2020; 44:2079-2087. [DOI: 10.1007/s00264-020-04699-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/29/2020] [Indexed: 11/28/2022]
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Rasras S, Mohammad Mamizadeh N, Safari H, Kiani A, Rahimi Z. Oral tranexamic acid for bleeding during spinal surgery: A randomized double-blind placebo clinical trial<span style="font-size:12px">Running title: Oral tranexamic acid for spinal surgery</span>. AIMS MEDICAL SCIENCE 2020. [DOI: 10.3934/medsci.2020005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
STUDY DESIGN This study was a retrospective cohort design. OBJECTIVE The objective of this study was to examine the impact of tranexamic acid (TXA) on total perioperative wound output following thoracic and lumbar spinal fusions. SUMMARY OF BACKGROUND DATA TXA has been extensively studied with regard to intraoperative blood loss and transfusion rates. Few studies have looked specifically at the effect of TXA on postoperative drain output. MATERIALS AND METHODS We examined blood loss patterns in 617 consecutive adult patients undergoing lumbar and/or thoracic fusions at a single institution from January 2009 to 2016. These patients were divided into TXA and non-TXA, as well as high-dose and low-dose TXA, groups and analyzed using a propensity score to account for differences between cohorts. RESULTS The TXA and non-TXA groups were demographically similar. The mean number of levels fused was higher in the TXA group (4.8 vs. 3.1 levels, P<0.01). There was a significant reduction in both intraoperative blood loss (77.7 mL per level, P=0.020) and postoperative drain output (83.3 mL per level, P=0.002) in the TXA group when examined on a per level fused basis, but no significant difference without controlling for a number of levels. Postoperative blood loss tended to be higher in the TXA group for surgeries involving >5 levels fused. There was a significantly less blood loss in the high-dose TKA group both intraoperatively (296.4 mL per level fused, P<0.001) and postoperatively (133.4 mL per level fused, P<0.001). CONCLUSIONS TXA significantly reduced both intraoperative and postoperative blood loss in lumbar and thoracic fusions when examined on a per level basis. However, with surgeries involving fusions >5 levels, TXA may increase postoperative drain output, with those losses offset by reduced intraoperative blood loss. High-dose TXA further reduced both intraoperative and postoperative blood loss as compared with low-dose TXA.
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Patient Blood Management During Lumbar Spinal Fusion Surgery. World Neurosurg 2019; 130:e566-e572. [DOI: 10.1016/j.wneu.2019.06.153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 11/23/2022]
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Yoo JS, Ahn J, Karmarkar SS, Lamoutte EH, Singh K. The use of tranexamic acid in spine surgery. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S172. [PMID: 31624738 PMCID: PMC6778277 DOI: 10.21037/atm.2019.05.36] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/13/2019] [Indexed: 11/06/2022]
Abstract
Patients undergoing surgical procedures of the spine with associated large volume blood loss often require perioperative blood conservation strategies. Synthetic antifibrinolytic medications such as tranexamic acid (TXA) may reduce blood transfusion requirements and postoperative complications following spinal procedures. Studies investigating the role of TXA in spine surgery have presented promising results and have proven its safety and efficacy. However, further investigation is needed to determine the optimal dosing regimen of TXA. In this article, we provide an overview of the basic science and pharmacology of TXA. A comprehensive summary of the findings from clinical trials and a review of the literature that demonstrate the risks and benefits of TXA in spine surgery are also presented.
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Affiliation(s)
- Joon S Yoo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Sailee S Karmarkar
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Eric H Lamoutte
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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The Safety and Efficacy of Tranexamic Acid in Adult Spinal Deformity Surgery: A Systematic Review and Meta-Analysis. Drugs 2019; 79:1679-1688. [DOI: 10.1007/s40265-019-01185-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Elmose S, Andersen MØ, Andresen EB, Carreon LY. Double-blind, randomized controlled trial of tranexamic acid in minor lumbar spine surgery: no effect on operative time, intraoperative blood loss, or complications. J Neurosurg Spine 2019; 31:194-200. [PMID: 30978683 DOI: 10.3171/2019.1.spine1814] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 01/29/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the effect of tranexamic acid (TXA) compared to placebo in low-risk adult patients undergoing elective minor lumbar spine surgery-specifically with respect to operative time, estimated blood loss, and complications. Studies have shown that TXA reduces blood loss during major spine surgery. There have been no previous studies on the effect of TXA in minor lumbar spine surgery in which these variables have been evaluated. METHODS The authors enrolled patients with ASA grades 1 to 2 scheduled to undergo lumbar decompressive surgery at Middelfart Hospital into a double-blind, randomized, placebo-controlled, parallel-group study. Patients with thromboembolic disease, coagulopathy, hypersensitivity to TXA, or a history of convulsion were excluded. Patients were randomly assigned, in blocks of 10, to one of 2 groups, TXA or placebo. Anticoagulation therapy was discontinued 2-7 days preoperatively. Prior to the incision, patients received either a bolus of TXA (10 mg/kg) or an equivalent volume of saline solution (placebo). Independent t-tests were used to compare differences between the 2 groups, with statistical significance set at p < 0.05. RESULTS Of the 250 patients enrolled, 17 patients were excluded, leaving 233 cases for analysis (117 in the TXA group and 116 in the placebo group). The demographics of the 2 groups were similar, except for a higher proportion of women in the TXA group (TXA 50% vs placebo 32%, p = 0.017). There was no significant between-groups difference in operative time (49.53 ± 18.26 vs 54.74 ± 24.49 minutes for TXA and placebo, respectively; p = 0.108) or intraoperative blood loss (55.87 ± 48.48 vs 69.14 ± 83.47 ml for TXA and placebo, respectively; p = 0.702). Postoperative blood loss measured from drain output was 62% significantly lower in the TXA group (13.03 ± 21.82 ml) than in the placebo group (34.61 ± 44.38 ml) (p < 0.001). There was no significant difference in number of dural lesions or postoperative spinal epidural hematomas, and there were no thromboembolic events. CONCLUSIONS Tranexamic acid did not have a statistically significant effect on operative time, intraoperative blood loss, or complications. This study gives no evidence to support the routine use of TXA during minor lumbar decompressive surgery.Clinical trial registration no.: NCT03714360 (clinicaltrials.gov).
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Does Prophylactic Administration of TXA Reduce Mean Operative Time and Postoperative Blood Loss in Posterior Approach Lumbar Spinal Fusion Surgery Performed for Degenerative Spinal Disease? Clin Spine Surg 2019; 32:E353-E358. [PMID: 30640750 DOI: 10.1097/bsd.0000000000000770] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a level III retrospective cohort study. OBJECTIVE To investigate association between prophylactic tranexamic acid (TXA) administration before 1 and 2-level posterior lumbar interbody fusion operations and perioperative blood loss (including intraoperative blood loss and postoperative drain output), mean operative time, postoperative transfusion, and postoperative venous thromboembolic events. SUMMARY OF BACKGROUND DATA TXA is a systemic antifibrinolytic that competitively inhibits lysine binding sites on plasminogen, reversibly blocking its binding to fibrin and impeding fibrinolysis and clot degradation. TXA's role in routine spinal surgery remains poorly described. Most spinal literature on perioperative TXA administration has considered operations performed for major adult and pediatric spinal deformity. METHODS Two groups, a study group composed of 75 patients who underwent 1 and 2-level posterior lumbar interbody fusion operations for degenerative indications who received TXA before the start of the procedure, and a control group composed of 75 patients who underwent similar surgeries for the same indications and did not receive TXA preoperatively, were retrospectively enrolled. Demographic, laboratory, and surgical data were collected and analyzed. RESULTS No statistically significant differences were found between groups with respect to surgery type, home anticoagulation, postoperative anticoagulation, preoperative hemoglobin and hematocrit, estimated intraoperative blood loss, postoperative day 2 drain output, postoperative day 3 drain output, rate of postoperative transfusion, and rate of postoperative thromboembolic events. Statistically significant reductions were noted in the TXA group with regards to postoperative day 1 drain output (P<0.0041), total postoperative drain output (P=0.027), and mean surgical time (P<0.0001). CONCLUSIONS In the present study, perioperative TXA administration was associated with reduced postoperative drain output and surgical time. Further higher-level studies are required to investigate the safety and utility of TXA's routine use in 1 and 2-level posterior lumbar fusion operations performed for degenerative indications.
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Chiang ER, Chen KH, Wang ST, Ma HL, Chang MC, Liu CL, Chen TH. Intra-articular Injection of Tranexamic Acid Reduced Postoperative Hemarthrosis in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study. Arthroscopy 2019; 35:2127-2132. [PMID: 31227397 DOI: 10.1016/j.arthro.2019.02.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 02/06/2019] [Accepted: 02/08/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the effect of intra-articular injection of tranexamic acid (TXA) in patients receiving arthroscopic anterior cruciate ligament reconstruction (ACLR). METHODS A total of 304 patients were included in this study, which was performed between August 2017 and April 2018. Single-bundle reconstructions using autologous hamstring tendon grafts were performed in all patients. Patients were randomized into 2 groups: Group 1 patients (TXA group) received the index procedure with a 10-mL intra-articular injection of TXA (100 mg/mL). Group 2 patients (control group) received the index procedure without TXA injections. An intra-articular suction drain was placed in the joint and clamped for 2 hours after the procedure. The volume of drainage was recorded 24 hours after surgery. Clinical evaluations using the International Knee Documentation Committee functional score, range of motion, and a visual analog scale pain score were performed on day 3 and at week 4 postoperatively. RESULTS Twenty-four hours after surgery, a significant decrease in the amount of drainage was observed in patients receiving intra-articular injections (TXA group, 56.1 ± 34.1 mL; control group, 80.1 ± 48 mL; P < .05). On day 3 and at week 4, significantly reduced pain scores were reported in the TXA group. However, at week 4, clinical function scores did not show significant differences between the 2 groups. CONCLUSIONS Intra-articular injection of TXA could significantly reduce postoperative intra-articular bleeding in the first 24 hours in patients receiving arthroscopic ACLR. TXA injection may also decrease pain and the grade of hemarthrosis in the early postoperative period. No systemic side effects or need for aspiration was noted during the follow-up period. Therefore, intra-articular injection of TXA could be considered an effective and relatively safe solution to reduce postoperative bleeding and pain in ACLR patients. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- En-Rung Chiang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, and National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Kun-Hui Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, and National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Shih-Tien Wang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, and National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Hsiao-Li Ma
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, and National Yang-Ming University School of Medicine, Taipei, Taiwan.
| | - Ming-Chau Chang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, and National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chien-Lin Liu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, and National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Tain-Hsiung Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, and National Yang-Ming University School of Medicine, Taipei, Taiwan
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Damade C, Tesson G, Gilard V, Vigny S, Foulongne E, Gauthé R, Ould-Slimane M. Blood loss and perioperative transfusions related to surgery for spinal tumors. Relevance of tranexamic acid. Neurochirurgie 2019; 65:377-381. [PMID: 31202780 DOI: 10.1016/j.neuchi.2019.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/12/2019] [Accepted: 05/17/2019] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) has been shown to reduce bleeding. Patients with spinal tumors are fragile and acute anemia may be harmful. Tumor excision surgery is reputed to be hemorrhagic and treatment may increase thromboembolic complications. The aim of this study was to compare blood loss with or without perioperative TXA injection. The transfusion-related and postoperative complications were documents. METHOD This retrospective analysis of prospectively collected data involved 83 patients with spinal tumors who underwent decompressive surgery associated with bone fixation. Tranexamic acid was used arbitrarily in 36 of them, while the other 47 did not receive TXA. The overall, intraoperative and postoperative blood loss was recorded. Blood loss was reported relative to the number of fixed levels and the number of levels decompressed by laminectomy. Transfusions were quantified in number of red blood cell packets and erythrocyte volume. Postoperative complications were documented. RESULTS Epidemiological and morphological data were similar between groups. There were no significant differences between the two groups in the overall, intraoperative, and postoperative blood loss. A significant reduction in postoperative bleeding was found in the TXA group when the volume was related to the number of decompressed levels. A significant reduction (P<0.05) in the volume of transfused blood was identified in the treated group. No predictor of blood loss was identified, and no additional complications occurred. CONCLUSION The efficacy of TXA appears to be moderate during spinal tumor surgery since it does not lead to a reduction in perioperative bleeding. However, a significant reduction in transfusion volume was found without an increase in complications.
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Affiliation(s)
- C Damade
- University hospital of Bordeaux, spine unit 1, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - G Tesson
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France
| | - V Gilard
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France; University hospital of Rouen, spine unit, department of neurosurgery, 1, rue de Germont, 76000 Rouen, France
| | - S Vigny
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France
| | - E Foulongne
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France
| | - R Gauthé
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France.
| | - M Ould-Slimane
- University hospital of Rouen, spine unit, department of orthopedic surgery, 1, rue de Germont, 76000 Rouen, France
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Intravenous and Oral Tranexamic Acid Are Equivalent at Reducing Blood Loss in Thoracolumbar Spinal Fusion: A Prospective Randomized Trial. Spine (Phila Pa 1976) 2019; 44:755-761. [PMID: 30540715 DOI: 10.1097/brs.0000000000002954] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective randomized trial of patients enrolled at a university affiliated tertiary medical center between February and December 2017. OBJECTIVE To compare perioperative blood loss in patients undergoing elective posterior thoracolumbar fusion who were treated with intravenous (IV) versus oral (PO) tranexamic acid (TXA). SUMMARY OF BACKGROUND DATA The use of antifibrinolytic agents such as TXA to decrease operative blood loss and allogenic blood transfusions is well documented in the literature. While evidence supports the use of IV and topical formulations of TXA in spine surgery, the use of PO TXA has not been studied. METHODS Eighty-three patients undergoing thoracolumbar fusion were randomized to receive 1.95 g of PO TXA 2 hours preoperatively or 2 g IV TXA (1 g before incision and 1 g before wound closure) intraoperatively. The sample was further stratified into three categories based on number of levels fused (1-2 level fusions, 3-5, and >5). The primary outcome was the reduction of hemoglobin. Secondary outcomes included calculated blood loss, drain output, postoperative transfusion, complications, and length of hospital stay. Equivalence analysis was performed with a two one-sided test (TOST). A P-value of <0.05 suggested equivalence between treatments. RESULTS Fourty three patients received IV TXA and 40 patients received PO TXA. Patient demographic factors were similar between groups except for body mass index (BMI). The mean reduction of hemoglobin was similar between IV and PO groups (3.36 g/dL vs. 3.43 g/dL, respectively; P = 0.01, equivalence). Similarly, the calculated blood loss was equivalent (1235 mL vs. 1312 mL, respectively; P = 0.02, equivalence). Eight patients (19%) in IV TXA group received a transfusion compared with five patients in PO TXA group (13%) (P = 0.44). One patient (2% and 3% in IV and PO, respectively) in each group experienced a deep venous thrombosis/pulmonary embolism (P = 0.96). CONCLUSION Patients treated with IV and PO TXA experienced the same perioperative blood loss after spinal fusions. Given its lower cost, PO TXA represents an excellent alternative to IV TXA in patients undergoing elective posterior thoracolumbar fusion and may improve healthcare cost-efficiency in the studied population. LEVEL OF EVIDENCE 1.
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Desai BD, Taylor DG, Chen CJ, Buell TJ, Mullin JP, Naik BI, Smith JS, Shaffrey CI. Utility of topical tranexamic acid for adult patients with spinal deformity and contraindications to systemic tranexamic acid: initial experience and report of 2 cases. J Neurosurg Spine 2019; 30:500-505. [PMID: 30684936 DOI: 10.3171/2018.9.spine18204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 09/26/2018] [Indexed: 01/09/2023]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent with demonstrated efficacy in reducing blood loss when administered systemically. However, in patients with contraindications to systemic or intravenous TXA, topical TXA (tTXA) has been shown to reduce perioperative blood loss, with some studies suggesting equivalence compared to systemic TXA. However, these studies have been conducted in healthy cohorts without contraindications to systemic TXA. In the surgical management of adult spinal deformity (ASD), comorbid disease is commonly encountered and may preclude use of systemic TXA. In this subset of patients with ASD who have contraindications for systemic TXA, use of tTXA has not been reported.The primary objective of this study was to conduct a systematic review on the use of tTXA in spine surgery and to present the authors' initial experience with tTXA as a novel hemostatic technique for 2 patients with medically complex ASD. Both patients had contraindications to systemic TXA use and underwent high-risk, long-segment fusion operations for correction of ASD. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to obtain studies related to spine surgery and tTXA from the National Institutes of Health PubMed (www.pubmed.gov) database. Criteria for final selection included a demonstration of quantitative data regarding operative or postoperative blood loss with the use of tTXA, and selection criteria were met by 6 articles.Topical TXA may offer a potential therapeutic role in reducing intra- and postoperative blood loss following long-segment spinal fusion surgeries, particularly for medically complex patients with contraindications to systemic TXA. It is reasonable to consider the use of tTXA as a salvage technique in complex high-risk patients with contraindications to systemic TXA, although further research is needed to delineate safety, magnitude of benefit, and optimization of dosing.
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Affiliation(s)
| | | | | | | | | | - Bhiken I Naik
- Departments of1Neurosurgery and
- 2Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
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The Use of Tranexamic Acid to Reduce Surgical Blood Loss: A Review Basic Science, Subspecialty Studies, and The Evolution of Use in Spine Deformity Surgery. Clin Spine Surg 2019; 32:46-50. [PMID: 30789494 DOI: 10.1097/bsd.0000000000000808] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Significant blood loss is often seen in orthopedic surgeries, especially complex spinal procedures that constitute long surgical times, large incisions, and rich blood supplies. Tranexamic acid (TXA), a synthetic analog of the amino acid lysine, has proven to be a cost-effective method in decreasing transfusion rates and avoiding complications associated with low blood volume. Recent data on TXA's use in spine surgery suggest that TXA remains both efficacious and safe, although the ideal dosing and timing of administration is still a point of disagreement. The purpose of this study is to review the literature for the use of TXA in spine surgery to better understand its safety profile and ideal dosage. This narrative review on TXA was conducted on prospective orthopedic studies that used TXA in spine deformity surgery. TXA in adult and pediatric spine surgery has decreased intraoperative and postoperative blood loss, decreasing the need for blood transfusions. The most common dose in the literature is a 10 mg/kg loading dose, followed by 1 mg/kg per hour. Although the proper dosing of TXA for spine surgery remains debatable, studies have proven that TXA is effective at reducing blood loss without increasing the risk of thrombotic events.
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