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Hidden Blood Loss, Infection and Cost-Effectiveness of Tranexamic Acid Protocol in Primary Total Knee Arthroplasty

Year 2018, Volume: 8 Issue: 2, 423 - 431, 29.06.2018
https://doi.org/10.31832/smj.420189

Abstract

Objective: The purpose was to evaluate the effect of combined administration of TXA on total blood loss, hidden blood loss, drain output, cost effectiveness and periprosthetic infection rate in patients undergoing unilateral primary knee arthroplasty.

Materials and Methods: We enrolled fifty-eight patients with primary gonarthrosis undergoing unilateral primary knee arthroplasty between May 2014 and December 2014. We compared 29 cases performed without the application of TXA to 29 cases performed with the application of TXA. Our TXA protocol consisted of three stages.

Results: Postoperative hemoglobin and hematocrit levels were found to be significantly lower in the non-TXA group. Estimated blood loss, hidden blood loss, and drain output were found to be higher in the non-TXA group. Transfusion rate was lower in TXA group. The blood bank costs were found to be higher in the non-TXA group. The total direct cost was also higher in the non-TXA group. This was average 29.9$ savings per case in the TXA group. No complication such as infection or thromboemboli was detected among the study groups.

Conclusion: Combined topical and continuous up to 24 hours intravenous administration of TXA reduced the total blood loss and decreased drainage volume, as well as reducing hidden blood loss.

References

  • Referans1 Good L, Peterson E and Lisander B. Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth 2003; 90: 596-599. 2003/04/17.Referans2 Lotke PA, Faralli VJ, Orenstein EM, et al. Blood loss after total knee replacement. Effects of tourniquet release and continuous passive motion. J Bone Joint Surg Am 1991; 73: 1037-1040. 1991/08/01.Referans3 Sehat KR, Evans R and Newman JH. How much blood is really lost in total knee arthroplasty?. Correct blood loss management should take hidden loss into account. Knee 2000; 7: 151-155. 2000/08/06.Referans4 Lee SH, Cho KY, Khurana S, et al. Less blood loss under concomitant administration of tranexamic acid and indirect factor Xa inhibitor following total knee arthroplasty: a prospective randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2013; 21: 2611-2617. 2012/10/12. DOI: 10.1007/s00167-012-2213-1.Referans5 Georgiadis AG, Muh SJ, Silverton CD, et al. A prospective double-blind placebo controlled trial of topical tranexamic acid in total knee arthroplasty. J Arthroplasty 2013; 28: 78-82. 2013/08/03. DOI: 10.1016/j.arth.2013.03.038.Referans6 Zhao-Yu C, Yan G, Wei C, et al. Reduced blood loss after intra-articular tranexamic acid injection during total knee arthroplasty: a meta-analysis of the literature. Knee Surg Sports Traumatol Arthrosc 2014; 22: 3181-3190. 2013/12/20. DOI: 10.1007/s00167-013-2814-3.Referans7 Imai N, Dohmae Y, Suda K, et al. Tranexamic acid for reduction of blood loss during total hip arthroplasty. J Arthroplasty 2012; 27: 1838-1843. 2012/06/19. DOI: 10.1016/j.arth.2012.04.024.Referans8 Astedt B. Clinical pharmacology of tranexamic acid. Scand J Gastroenterol Suppl 1987; 137: 22-25. 1987/01/01.Referans9 Schulman S. Pharmacologic tools to reduce bleeding in surgery. Hematology Am Soc Hematol Educ Program 2012; 2012: 517-521. 2012/12/13. DOI: 10.1182/asheducation-2012.1.517.Referans10 Alshryda S, Sarda P, Sukeik M, et al. Tranexamic acid in total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg Br 2011; 93: 1577-1585. 2011/12/14. DOI: 10.1302/0301-620X.93B12.26989.Referans11 Gandhi R, Evans HM, Mahomed SR, et al. Tranexamic acid and the reduction of blood loss in total knee and hip arthroplasty: a meta-analysis. BMC Res Notes 2013; 6: 184. 2013/05/09. DOI: 10.1186/1756-0500-6-184.Referans12 Huang F, Wu D, Ma G, et al. The use of tranexamic acid to reduce blood loss and transfusion in major orthopedic surgery: a meta-analysis. J Surg Res 2014; 186: 318-327. 2013/10/01. DOI: 10.1016/j.jss.2013.08.020.Referans13 Yang ZG, Chen WP and Wu LD. Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis. J Bone Joint Surg Am 2012; 94: 1153-1159. 2012/05/25. DOI: 10.2106/JBJS.K.00873.Referans14 Gaulrapp H and Eckstein S. [Value of ultrasound after endoprosthesis implantation of the knee joint]. Z Orthop Ihre Grenzgeb 2001; 139: 127-133. 2001/06/02. DOI: 10.1055/s-2001-15043.Referans15 Harrap RS, Whyte GS, Farrugia A, et al. Some characteristics of blood shed into the Solcotrans postoperative orthopaedic drainage/reinfusion system. Med J Aust 1992; 157: 95-96. 1992/07/20.Referans16 Sehat KR, Evans RL and Newman JH. Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br 2004; 86: 561-565. 2004/06/04.Referans17 Adelani MA, Johnson SR, Keeney JA, et al. Clinical outcomes following re-admission for non-infectious wound complications after primary total knee replacement. Bone Joint J 2014; 96-B: 619-621. 2014/05/03. DOI: 10.1302/0301-620X.96B5.33479.Referans18 Galat DD, McGovern SC, Hanssen AD, et al. Early return to surgery for evacuation of a postoperative hematoma after primary total knee arthroplasty. J Bone Joint Surg Am 2008; 90: 2331-2336. 2008/11/04. DOI: 10.2106/JBJS.G.01370.Referans19 Jamsen E, Huhtala H, Puolakka T, et al. Risk factors for infection after knee arthroplasty. A register-based analysis of 43,149 cases. J Bone Joint Surg Am 2009; 91: 38-47. 2009/01/06. DOI: 10.2106/JBJS.G.01686.Referans20 Parvizi J, Ghanem E, Joshi A, et al. Does "excessive" anticoagulation predispose to periprosthetic infection? J Arthroplasty 2007; 22: 24-28. 2007/10/11. DOI: 10.1016/j.arth.2007.03.007.Referans21 Nadler SB, Hidalgo JH and Bloch T. Prediction of blood volume in normal human adults. Surgery 1962; 51: 224-232. 1962/02/01.Referans22 Morais S, Ortega-Andreu M, Rodriguez-Merchan EC, et al. Blood transfusion after primary total knee arthroplasty can be significantly minimised through a multimodal blood-loss prevention approach. Int Orthop 2014; 38: 347-354. 2013/12/10. DOI: 10.1007/s00264-013-2188-7.Referans23 Madjdpour C and Spahn DR. Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications. Br J Anaesth 2005; 95: 33-42. 2004/10/16. DOI: 10.1093/bja/aeh290.Referans24 Ralley FE, Berta D, Binns V, et al. One intraoperative dose of tranexamic Acid for patients having primary hip or knee arthroplasty. Clin Orthop Relat Res 2010; 468: 1905-1911. 2010/01/12. DOI: 10.1007/s11999-009-1217-8.Referans25 Sepah YJ, Umer M, Ahmad T, et al. Use of tranexamic acid is a cost effective method in preventing blood loss during and after total knee replacement. J Orthop Surg Res 2011; 6: 22. 2011/05/24. DOI: 10.1186/1749-799X-6-22.Referans26 Ross J and Al-Shahi Salman R. The frequency of thrombotic events among adults given antifibrinolytic drugs for spontaneous bleeding: systematic review and meta-analysis of observational studies and randomized trials. Curr Drug Saf 2012; 7: 44-54. 2012/06/06.Referans27 Struijk-Mulder MC, Horstmann WG, Verheyen CC, et al. Ten-year follow-up on Dutch orthopaedic blood management (DATA III survey). Arch Orthop Trauma Surg 2014; 134: 15-20. 2013/11/28. DOI: 10.1007/s00402-013-1893-4.Referans28 Iwai T, Tsuji S, Tomita T, et al. Repeat-dose intravenous tranexamic acid further decreases blood loss in total knee arthroplasty. Int Orthop 2013; 37: 441-445. 2013/02/02. DOI: 10.1007/s00264-013-1787-7.Referans29 Astedt B, Liedholm P and Wingerup L. The effect of tranexamic acid on the fibrinolytic activity of vein walls. Ann Chir Gynaecol 1978; 67: 203-205. 1978/01/01.Referans30 Gillette BP, DeSimone LJ, Trousdale RT, et al. Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty. Clin Orthop Relat Res 2013; 471: 150-154. 2012/07/21. DOI: 10.1007/s11999-012-2488-z.

Hidden Blood Loss, Infection and Cost-Effectiveness of Tranexamic Acid Protocol in Primary Total Knee Arthroplasty

Year 2018, Volume: 8 Issue: 2, 423 - 431, 29.06.2018
https://doi.org/10.31832/smj.420189

Abstract

Objective: The purpose was to evaluate the effect of combined administration of TXA on total blood loss, hidden blood loss, drain output, cost effectiveness and periprosthetic infection rate in patients undergoing unilateral primary knee arthroplasty.

Materials and Methods: We enrolled fifty-eight patients with primary gonarthrosis undergoing unilateral primary knee arthroplasty between May 2014 and December 2014. We compared 29 cases performed without the application of TXA to 29 cases performed with the application of TXA. Our TXA protocol consisted of three stages.

Results: Postoperative hemoglobin and hematocrit levels were found to be significantly lower in the non-TXA group. Estimated blood loss, hidden blood loss, and drain output were found to be higher in the non-TXA group. Transfusion rate was lower in TXA group. The blood bank costs were found to be higher in the non-TXA group. The total direct cost was also higher in the non-TXA group. This was average 29.9$ savings per case in the TXA group. No complication such as infection or thromboemboli was detected among the study groups.

Conclusion: Combined topical and continuous up to 24 hours intravenous administration of TXA reduced the total blood loss and decreased drainage volume, as well as reducing hidden blood loss.

References

  • Referans1 Good L, Peterson E and Lisander B. Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth 2003; 90: 596-599. 2003/04/17.Referans2 Lotke PA, Faralli VJ, Orenstein EM, et al. Blood loss after total knee replacement. Effects of tourniquet release and continuous passive motion. J Bone Joint Surg Am 1991; 73: 1037-1040. 1991/08/01.Referans3 Sehat KR, Evans R and Newman JH. How much blood is really lost in total knee arthroplasty?. Correct blood loss management should take hidden loss into account. Knee 2000; 7: 151-155. 2000/08/06.Referans4 Lee SH, Cho KY, Khurana S, et al. Less blood loss under concomitant administration of tranexamic acid and indirect factor Xa inhibitor following total knee arthroplasty: a prospective randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2013; 21: 2611-2617. 2012/10/12. DOI: 10.1007/s00167-012-2213-1.Referans5 Georgiadis AG, Muh SJ, Silverton CD, et al. A prospective double-blind placebo controlled trial of topical tranexamic acid in total knee arthroplasty. J Arthroplasty 2013; 28: 78-82. 2013/08/03. DOI: 10.1016/j.arth.2013.03.038.Referans6 Zhao-Yu C, Yan G, Wei C, et al. Reduced blood loss after intra-articular tranexamic acid injection during total knee arthroplasty: a meta-analysis of the literature. Knee Surg Sports Traumatol Arthrosc 2014; 22: 3181-3190. 2013/12/20. DOI: 10.1007/s00167-013-2814-3.Referans7 Imai N, Dohmae Y, Suda K, et al. Tranexamic acid for reduction of blood loss during total hip arthroplasty. J Arthroplasty 2012; 27: 1838-1843. 2012/06/19. DOI: 10.1016/j.arth.2012.04.024.Referans8 Astedt B. Clinical pharmacology of tranexamic acid. Scand J Gastroenterol Suppl 1987; 137: 22-25. 1987/01/01.Referans9 Schulman S. Pharmacologic tools to reduce bleeding in surgery. Hematology Am Soc Hematol Educ Program 2012; 2012: 517-521. 2012/12/13. DOI: 10.1182/asheducation-2012.1.517.Referans10 Alshryda S, Sarda P, Sukeik M, et al. Tranexamic acid in total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg Br 2011; 93: 1577-1585. 2011/12/14. DOI: 10.1302/0301-620X.93B12.26989.Referans11 Gandhi R, Evans HM, Mahomed SR, et al. Tranexamic acid and the reduction of blood loss in total knee and hip arthroplasty: a meta-analysis. BMC Res Notes 2013; 6: 184. 2013/05/09. DOI: 10.1186/1756-0500-6-184.Referans12 Huang F, Wu D, Ma G, et al. The use of tranexamic acid to reduce blood loss and transfusion in major orthopedic surgery: a meta-analysis. J Surg Res 2014; 186: 318-327. 2013/10/01. DOI: 10.1016/j.jss.2013.08.020.Referans13 Yang ZG, Chen WP and Wu LD. Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis. J Bone Joint Surg Am 2012; 94: 1153-1159. 2012/05/25. DOI: 10.2106/JBJS.K.00873.Referans14 Gaulrapp H and Eckstein S. [Value of ultrasound after endoprosthesis implantation of the knee joint]. Z Orthop Ihre Grenzgeb 2001; 139: 127-133. 2001/06/02. DOI: 10.1055/s-2001-15043.Referans15 Harrap RS, Whyte GS, Farrugia A, et al. Some characteristics of blood shed into the Solcotrans postoperative orthopaedic drainage/reinfusion system. Med J Aust 1992; 157: 95-96. 1992/07/20.Referans16 Sehat KR, Evans RL and Newman JH. Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br 2004; 86: 561-565. 2004/06/04.Referans17 Adelani MA, Johnson SR, Keeney JA, et al. Clinical outcomes following re-admission for non-infectious wound complications after primary total knee replacement. Bone Joint J 2014; 96-B: 619-621. 2014/05/03. DOI: 10.1302/0301-620X.96B5.33479.Referans18 Galat DD, McGovern SC, Hanssen AD, et al. Early return to surgery for evacuation of a postoperative hematoma after primary total knee arthroplasty. J Bone Joint Surg Am 2008; 90: 2331-2336. 2008/11/04. DOI: 10.2106/JBJS.G.01370.Referans19 Jamsen E, Huhtala H, Puolakka T, et al. Risk factors for infection after knee arthroplasty. A register-based analysis of 43,149 cases. J Bone Joint Surg Am 2009; 91: 38-47. 2009/01/06. DOI: 10.2106/JBJS.G.01686.Referans20 Parvizi J, Ghanem E, Joshi A, et al. Does "excessive" anticoagulation predispose to periprosthetic infection? J Arthroplasty 2007; 22: 24-28. 2007/10/11. DOI: 10.1016/j.arth.2007.03.007.Referans21 Nadler SB, Hidalgo JH and Bloch T. Prediction of blood volume in normal human adults. Surgery 1962; 51: 224-232. 1962/02/01.Referans22 Morais S, Ortega-Andreu M, Rodriguez-Merchan EC, et al. Blood transfusion after primary total knee arthroplasty can be significantly minimised through a multimodal blood-loss prevention approach. Int Orthop 2014; 38: 347-354. 2013/12/10. DOI: 10.1007/s00264-013-2188-7.Referans23 Madjdpour C and Spahn DR. Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications. Br J Anaesth 2005; 95: 33-42. 2004/10/16. DOI: 10.1093/bja/aeh290.Referans24 Ralley FE, Berta D, Binns V, et al. One intraoperative dose of tranexamic Acid for patients having primary hip or knee arthroplasty. Clin Orthop Relat Res 2010; 468: 1905-1911. 2010/01/12. DOI: 10.1007/s11999-009-1217-8.Referans25 Sepah YJ, Umer M, Ahmad T, et al. Use of tranexamic acid is a cost effective method in preventing blood loss during and after total knee replacement. J Orthop Surg Res 2011; 6: 22. 2011/05/24. DOI: 10.1186/1749-799X-6-22.Referans26 Ross J and Al-Shahi Salman R. The frequency of thrombotic events among adults given antifibrinolytic drugs for spontaneous bleeding: systematic review and meta-analysis of observational studies and randomized trials. Curr Drug Saf 2012; 7: 44-54. 2012/06/06.Referans27 Struijk-Mulder MC, Horstmann WG, Verheyen CC, et al. Ten-year follow-up on Dutch orthopaedic blood management (DATA III survey). Arch Orthop Trauma Surg 2014; 134: 15-20. 2013/11/28. DOI: 10.1007/s00402-013-1893-4.Referans28 Iwai T, Tsuji S, Tomita T, et al. Repeat-dose intravenous tranexamic acid further decreases blood loss in total knee arthroplasty. Int Orthop 2013; 37: 441-445. 2013/02/02. DOI: 10.1007/s00264-013-1787-7.Referans29 Astedt B, Liedholm P and Wingerup L. The effect of tranexamic acid on the fibrinolytic activity of vein walls. Ann Chir Gynaecol 1978; 67: 203-205. 1978/01/01.Referans30 Gillette BP, DeSimone LJ, Trousdale RT, et al. Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty. Clin Orthop Relat Res 2013; 471: 150-154. 2012/07/21. DOI: 10.1007/s11999-012-2488-z.
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Details

Primary Language English
Subjects Health Care Administration
Journal Section Articles
Authors

Hakkı Çağdaş Basat 0000-0003-3301-2529

Berk Güçlü This is me 0000-0002-3705-3435

Ömer Bozduman 0000-0002-8392-1846

Yasin Köker 0000-0002-8392-1846

Cihan Kırçıl 0000-0001-9758-5778

Hicabi Sezgin This is me 0000-0002-1332-3656

Publication Date June 29, 2018
Submission Date May 4, 2018
Published in Issue Year 2018 Volume: 8 Issue: 2

Cite

AMA Basat HÇ, Güçlü B, Bozduman Ö, Köker Y, Kırçıl C, Sezgin H. Hidden Blood Loss, Infection and Cost-Effectiveness of Tranexamic Acid Protocol in Primary Total Knee Arthroplasty. Sakarya Tıp Dergisi. June 2018;8(2):423-431. doi:10.31832/smj.420189

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