Impact of tranexamic acid on coagulation parameters in patients undergoing total knee replacement surgeries under tourniquet: an observational study
DOI:
https://doi.org/10.18203/2320-6012.ijrms20181015Keywords:
Blood loss, Cement, Knee replacement, Platelets, Thrombosis, TourniquetAbstract
Background: A growing body of evidence has shown Tranexamic Acid (TXA) is effective in decreasing perioperative blood loss and transfusion requirements in both primary and revision joint arthroplasty. TXA is a synthetic drug which limits blood loss through inhibition of fibrinolysis and clot degradation. It helps reduce requirement of colloids and crystalloids and hence provides better haemodynamic stability. The aim of this study was to detect the effect of tranexamic acid on coagulation parameters and effect on bleeding in knee replacement surgeries performed under tourniquet.
Methods: Patients undergone surgeries of Total Knee Replacement (TKR) performed under tourniquet were included in the study. A single dosage of 20 mg/kg per body weight of tranexamic acid was administered after application of a tourniquet. Three times blood sample was collected, and coagulation parameters were recorded and compared. The first sample was collected at the time of TXA injection and application of a tourniquet, second after 4 hours and third after 24 hours post TXA injection. Coagulation parameters noted were analyzed using Statistical analysis by SPSS software. All parameters were compared in relation to baseline i.e. at the time of TXA injection.
Results: On comparison of demographic profile, morbidity, sofa score and hemodynamic parameters there was the insignificant difference (P > 0.05). Repeated measures of ANOVA at 95% Confidential Interval P value was 0.000 which is less than the significant level that is 0.05 so that value of Platelet Function (PF), Activated Coagulation Time (ACT) and Clot Rate (CR) at 0 hrs, 04 hrs and 24 hrs was statistically significant. Correlation between blood loss and difference of the value of ACT at 0 hrs and 04 hrs is a small negative correlation but statistically nonsignificant (P value is 0.359).
Conclusions: After TXA administration there is a change in coagulation parameters like an Activated Coagulation Time (ACT), Platelet Function (PF), and Clot Rate (CR) measured at three intervals, hence it can be a guide to detect early derangement in the coagulation profile in a patient undergoing knee replace surgery. TXA correlation between blood loss with changes in parameters of coagulation i.e. ACT, PF and CR were noted but not significant.
References
Carson JL, Duff A, Berlin JA, Lawrence VA, Poses RM, Huber EC. Perioperative blood transfusion and postoperative mortality. JAMA. 1998;279:199-205.
Zohar, E, Fredman, B, Ellis, M, Luban, I, Stern, A, Jedeikin R. A comparative study of the post-operative allogeneic blood-sparing effect of TXA vs. acute normovolaemic haemodilution after total knee replacement. Anesth Analg. 1999;89:1382-7.
Hiippala, S, Strid, L, Wennerstrand, M, Arvela, V, Mantyla, S, Ylinen, J, et al. TXA (Cyklokapron) reduces peri-operative blood loss associated with total knee arthroplasty. Br J Anaesth. 1995;74:534-7.
Howes, JP, Sharma V, Cohen AT. TXA reduces blood loss after knee arthroplasty. J Bone Joint Surg Br. 1996;78:995-6.
Hynes MC, Calder P, Rosenfeld P, Calder P, Scott G. The use of TXA to reduce blood loss during total hip arthroplasty: an observational study. Annals of The Royal College of Surgeons of England 2005;87(2):99-101.
Kagoma YK, Crowther MA, Douketis J, Bhandari M, Eikelboom J, Lim W. Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopedic surgery: a systematic review of randomized trials. Thromb Res. 2009;123:687-96.
Ralley FE, Berta D, Binns V, Howard J, Naudie DD. One intraoperative dose of tranexamic acid for patients having primary hip or knee arthroplasty. Clinical Orthopaedics and Related Research®. 2010;468(7):1905-11.
Zufferey P, Merquiol F, Laporte S, Decousus H, Mismetti P, Auboyer C, et al. Do antifibrinolytics reduce allogeneic blood transfusion in orthopedic surgery?. Anesthesiology: J Ame Society Anesthesiol. 2006;105(5):1034-46.
Möhnle P, Snyder-Ramos SA, Miao Y, Kulier A, Böttiger BW, Levin J, et al. Postoperative red blood cell transfusion and morbid outcome in uncomplicated cardiac surgery patients. Intensive care medicine. 2011;37(1):97-109.
Danninger T, Memtsoudis SG. TXA and orthopedic surgery-the search for the holy grail of blood conservation. Ann Transl Med. 2015;3(6):77.
Hett DA, Walker D, Pilkington SN, Smith DC. Sonoclot analysis. British J anaesthesia. 1995;75(6):771-6.
Gupta A, Gupta N. TXA in total knee replacement surgeries: Some concerns. Indian J Anaesth. 2012;56(3):320-1.
Williamson LM, Lowe S, Love EM, Cohen H, Soldan K, McClelland DB, et al. Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports. BMJ. 1999;319(7201):16-9.
Keating EM, Ritter MA. Transfusion options for total joint replacement. J Arthroplasty. 2002;17:22-7.
Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, et al. An analysis of blood management in patients having a total hip or knee arthroplasty. JBJS. 1999;81(1):2-10.
Salido JA, Marin LA, Gomez LA, Zorrilla P, Martinez C. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors. J Bone Joint Surg Am. 2002;84:216-20.
Huët C, Salmi LR, Fergusson D, Koopman-van Gemert AW, Rubens F, Laupacis A. A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopedic surgery. Anesthesia Analgesia. 1999;89(4):861.
Moore EE, Dunn EL, Breslich DJ, Galloway WB. Platelet abnormalities associated with massive autotransfusion. J trauma. 1980;20(12):1052-6.
Jove M, Landon G, Frei D, Guilfoyle M, Young DC. Baseline hemoglobin as a predictor of risk of transfusion and response to epoetin alfa in orthopedic surgery patients. Ame J orthopedics (Belle Mead, NJ). 1996;25(8):533-42.
Alvarez JC, Santiveri FX, Ramos I, Vela E, Puig L, Escolano F. Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied. Transfusion. 2008;48(3):519-25.
Astedt B. Clinical pharmacology of TXA. Scand J Gastroenterol Suppl. 1987;137;22-25.
Ekba¨G, Axelsson K, Ryttberg L, Bror E, Jill K, Johan W, et al. Tranexamic acid reduces blood loss in total hip replacement surgery. Anesth Analg. 2000;91:1124-30.
Shore-Lesserson L, Reich DL, Vela-Cantos F, Ammar T, Ergin MA. Tranexamic acid reduces transfusions and mediastinal drainage in repeat cardiac surgery. Anesth Analgesia. 1996;83(1):18-26.
Brown RS, Thwaites BK, Mongan PD. TXA is effective in decreasing postoperative bleeding and transfusions in primary coronary artery bypass operations: a double-blind, randomized, placebo-controlled trial. Anesth Analg. 1997;85:963-7017.
Mongan PD, Brown RS, Thwaites BK. TXA and aprotinin reduce postoperative bleeding and transfusions during primary coronary revascularization. Anesth Analg. 1998;87:258.
Fitch JC, Elefteriades JA. Beneficial Effect of Both Tranexamic Acid and Aprotinin on Blood Loss Reduction in Reoperative Valve Replacement Surgery. Circulation. 1997;96(9S):100II-1II.
Murkin JM, Shannon NA, Bourne RB, Rorabeck CH, Cruickshank M, Wyile G. Aprotinin decreases blood loss in patients undergoing revision or bilateral total hip arthroplasty. Anesthesia Analgesia. 1995;80(2):343-8.
Raut VV, Stone MH, Wroblewski BM. Reduction of postoperative blood loss after press-fit condylar knee arthroplasty with use of a femoral intramedullary plug. J Bone Joint Surg Am. 1993;75:1356-7.
Gomez-Barrena E, Ortega-Andreu M, Padilla-Eguiluz NG, Pérez-Chrzanowska H, Figueredo-Zalve R. Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial. JBJS. 2014;96(23):1937-44.
Janssens M, Joris J, David JL, Lemaire R, Lamy M. High-dose aprotinin reduces blood loss in patients undergoing total hip replacement surgery. Anesthesiology. 1994;80(1):23-9.
Christie J, Robinson CM, Pell AC, McBirnie J, Burnett R. Transcardiac echocardiography during invasive intramedullary procedures. Bone Joint Journal. 1995;77(3):450-5.
Ekba¨ck G, Carlsson O, Schott U. Sonoclot coagulation analysis: a study of test variability. J Cardiothorac Vasc Anesth. 1999;13:393-7.
Lozano M, Basora M, Peidro L, Merino I, Segur JM, Pereira A, et al. Effectiveness and safety of tranexamic acid administration during total knee arthroplasty. Vox sanguinis. 2008;95(1):39-44.
Reid RW, Zimmerman AA, Laussen PC, Mayer JE, Gorlin JB, Burrows FA. The efficacy of tranexamic acid versus placebo in decreasing blood loss in pediatric patients undergoing repeat cardiac surgery. Anesthesia analgesia. 1997;84(5):990-6.
Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anaesthesiol. 2008;108:71-7
Cid J, Lozano M. TXA reduces allogeneic red cell transfusions in patients undergoing total knee arthroplasty: results of a meta-analysis of randomized controlled trials. Transfusion. 2005;45:1302-7.
Poeran J, Rasul R, Suzuki S, Danninger T, Mazumdar M, Opperer M, et al. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ. 2014;349:g4829.
Tanaka N, Sakahashi H, Sato E, Hirose K, Ishima T, Ishii S. Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. Bone Joint J. 2001;83(5):702-5.
Benoni G, Bjo¨rkman S, Fredin H. Application of pharmacokinetic data from healthy volunteers for the prediction of plasma concentrations of TXA in surgical patients. Clin Drug Invest. 1995;10:280-7.
