Intravenous and Topical Tranexamic Acid - what can we learn from knee surgeons?
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Intravenous and Topical Tranexamic Acid Alone Are Superior to Tourniquet Use for Primary Total Knee Arthroplasty A Prospective, Randomized Controlled Trial
These authors randomized 150 patients having total knee arthroplasty to 3 groups.
Group A was treated with a tourniquet as well as multiple doses of intravenous tranexamic acid (TXA) (20 mg/kg 5 to 10 minutes before the skin incision and 10 mg/kg 3, 6, 12, and 24 hours later) along with 1 g of topical TXA,
Group B was treated the same as Group A but without the tourniquet, and
Group C was treated with the tourniquet only.
The amount of intraoperative blood loss was similar for the 3 groups.
Group B had significantly less hidden blood loss than Group A (p = 0.018) and Group C (p < 0.001).
No significant differences (p > 0.05) were observed between Group A and Group B with regard to total blood loss, drainage volume, intraoperative blood loss, transfusion rate, or maximum change in the hemoglobin (Hb) level.
They also found significantly more benefits for Group B compared with Groups A and C with regard to postoperative swelling ratio, levels of inflammatory biomarkers, visual analog scale (VAS) pain scores, range of motion at discharge, Hospital for Special Surgery (HSS) score, and patient satisfaction.
Neither DVT nor PE occurred in any patient. Postoperatively, routine Doppler ultrasound showed that 13 patients (6 from Group A, 4 from Group B, and 3 from Group C) developed intramuscular venous thrombosis.
One patient from Group A and 3 patients from Group C developed superficial infection, which was controlled with dressing changes and oral antibiotics. Wound secretion occurred in 15 patients (6 from Group A and 9 from Group C).
No wound secretion was observed in Group B during the entire follow-up period, and this represented a significant difference compared with Group A (p = 0.027) and Group C (p = 0.003).
Blistering was reported in 3 patients from Group C and no patients in Group A or B
They concluded that patients treated with multiple doses of intravenous and topical TXA without a tourniquet had less hidden blood loss, a lower ratio of postoperative knee swelling, less postoperative knee pain, lower levels of inflammatory biomarkers, better early knee function, and even better early satisfaction than those treated with a tourniquet.
Comment: Bruising and swelling are not uncommon after shoulder arthroplasty as shown below. This swelling (resulting from 'hidden blood loss') can be quite painful and can interfere with the patient's ability to perform range of motion exercises. The reduction in inflammatory markers in this study is of interest; perhaps due to the damage from a tourniquet.
For these reasons, TXA is an appealing approach to reducing preoperative blood loss in shoulder surgery. This study combined topical and a vigorous IV administration protocol. We currently use 1 gm before and 1 gm at the conclusion of surgery along with 1 gm administered topically, but there is uncertainty regarding the optimal dosage.
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These authors randomized 150 patients having total knee arthroplasty to 3 groups.
Group A was treated with a tourniquet as well as multiple doses of intravenous tranexamic acid (TXA) (20 mg/kg 5 to 10 minutes before the skin incision and 10 mg/kg 3, 6, 12, and 24 hours later) along with 1 g of topical TXA,
Group B was treated the same as Group A but without the tourniquet, and
Group C was treated with the tourniquet only.
The amount of intraoperative blood loss was similar for the 3 groups.
Group B had significantly less hidden blood loss than Group A (p = 0.018) and Group C (p < 0.001).
No significant differences (p > 0.05) were observed between Group A and Group B with regard to total blood loss, drainage volume, intraoperative blood loss, transfusion rate, or maximum change in the hemoglobin (Hb) level.
They also found significantly more benefits for Group B compared with Groups A and C with regard to postoperative swelling ratio, levels of inflammatory biomarkers, visual analog scale (VAS) pain scores, range of motion at discharge, Hospital for Special Surgery (HSS) score, and patient satisfaction.
Neither DVT nor PE occurred in any patient. Postoperatively, routine Doppler ultrasound showed that 13 patients (6 from Group A, 4 from Group B, and 3 from Group C) developed intramuscular venous thrombosis.
One patient from Group A and 3 patients from Group C developed superficial infection, which was controlled with dressing changes and oral antibiotics. Wound secretion occurred in 15 patients (6 from Group A and 9 from Group C).
No wound secretion was observed in Group B during the entire follow-up period, and this represented a significant difference compared with Group A (p = 0.027) and Group C (p = 0.003).
Blistering was reported in 3 patients from Group C and no patients in Group A or B
They concluded that patients treated with multiple doses of intravenous and topical TXA without a tourniquet had less hidden blood loss, a lower ratio of postoperative knee swelling, less postoperative knee pain, lower levels of inflammatory biomarkers, better early knee function, and even better early satisfaction than those treated with a tourniquet.
Comment: Bruising and swelling are not uncommon after shoulder arthroplasty as shown below. This swelling (resulting from 'hidden blood loss') can be quite painful and can interfere with the patient's ability to perform range of motion exercises. The reduction in inflammatory markers in this study is of interest; perhaps due to the damage from a tourniquet.
For these reasons, TXA is an appealing approach to reducing preoperative blood loss in shoulder surgery. This study combined topical and a vigorous IV administration protocol. We currently use 1 gm before and 1 gm at the conclusion of surgery along with 1 gm administered topically, but there is uncertainty regarding the optimal dosage.
====
The reader may also be interested in these posts:
Healing through joint replacement
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