TXA
Tranexamic Acid
Please check out this Grand Rounds lecture given at Stanford on the topic of Tranexamic Acid and its usage in total joint arthroplasty. The content of this lecture is largely based on this 2018 paper by Fillingham et al. that was published in The Journal of Arthroplasty. These are the current guidelines endorsed by the orthopedic hip and knee societies, the American Academy of Orthopedic Surgeons, and our friends at the Anesthesia Society of Regional Anesthesia (ASRA).
The Tranexamic Acid protocol for joints cases at Stanford are as follows: 1 gram given before incision, and 1 gram at the beginning of closure. Is this evidenced based? Please keep reading to find out...
A very brief summary of recent literature:
Studies suggest that TXA, when dosed as described above, decreases perioperative blood loss and transfusion for THA & TKA. This includes the post-op period (which is more meaningful in the case of TKA, where intraop blood loss is minimal due to tourniquet use)
Sounds promising ... but what about DVTs? TXA, when dosed as described above, has NOT been shown to increase the likelihood of VTE.
However, there is little data on the use of TXA in patients who are specifically at highest risk for VTE, such as patients with a history of DVT, PE, MI, CVA, coronary artery stent placement, CABG, or those with a prothrombotic condition. There is one retrospective study (see 3rd reference at bottom) that suggests it is safe in this population, but the study has its limitations. Ultimately it is our decision as anesthesiologists whether or not to administer TXA in this patient population weighing the risks and benefits on a case-by-case basis.
Summary of Recommendations
Guideline Question 1
For patients undergoing primary TJA, what method of administration of TXA, compared to placebo, reduces the risk of transfusion and/or reduces blood loss?
Response/Recommendation
Administration of intravenous (IV), topical, and oral TXA as well as combinations of individual formulations of TXA is an effective strategy when compared to placebo for reducing calculated blood loss and the need for transfusion during the perioperative episode of a primary TJA.
Strength of Recommendation
Strong.
Guideline Question 2
For patients undergoing primary TJA, what method of administration of TXA, compared to a different method of administration, reduces the risk of transfusion and/or reduces blood loss?
Response/Recommendation
The analysis of studies did not identify a clearly superior method, or combinations of methods, for the administration of TXA. All methods of administration effectively demonstrate equivalent efficacy at reducing calculated blood loss and the risk of transfusion during the perioperative episode of a primary TJA.
Strength of Recommendation
Strong.
Guideline Question 3
For patients undergoing primary TJA, does the dose amount of IV or topical TXA affect the risk of transfusion and/or reduction in blood loss?
Response/Recommendation
Within the context of the TXA doses used in primary TJA, the dose amount of TXA was not found to significantly affect its reduction of calculated blood loss or the need for transfusion during the perioperative episode of a primary TJA.
Strength of Recommendation
Strong.
Guideline Question 4
For patients undergoing primary TJA, do multiple doses of IV or oral TXA, compared to a single dose, reduce the risk of transfusion and/or reduce blood loss?
Response/Recommendation
Administration of multiple doses of IV or oral TXA compared to a single dose of IV or oral TXA does not significantly alter the amount of calculated blood loss and need for transfusion during the perioperative episode of a primary TJA.
Strength of Recommendation
Strong.
Guideline Question 5
For patients undergoing primary TJA, does the timing of the administration of TXA in relation to the surgical incision affect the ability of TXA to reduce the risk of transfusion and/or blood loss?
Response/Recommendation
In primary TJA, administration of IV TXA before the incision potentially reduces blood loss and the need for transfusion compared to its administration after incision.
Strength of Recommendation
Moderate.
Guideline Question 6
For patients undergoing primary TJA without a history of a venous thromboembolic event (VTE), does the treatment with TXA affect the risk of VTE?
Response/Recommendation
Administration of IV, topical, and oral TXA in patients without a known history of a VTE does not increase the risk of developing a VTE compared to placebo during the perioperative episode of a primary TJA.
Strength of Recommendation
Strong.
Guideline Question 7
For patients undergoing primary TJA with a history of a VTE, myocardial infarction (MI), cerebrovascular accident (CVA), transient ischemic attack (TIA), and/or vascular stent placement, does the treatment with TXA affect the risk of VTE?
Response/Recommendation
There is a paucity of randomized, clinical trials on the risk of adverse effects of IV, topical, and oral TXA in patients with a known history of a VTE, MI, CVA, TIA, and/or vascular stent placement. The existing high-quality literature regarding administration of TXA in patients of generally higher comorbidity burden does not suggest increased risk of adverse thromboembolic events during the perioperative episode of a primary TJA.
Strength of Recommendation
Moderate.
Guideline Question 8
For patients undergoing primary TJA, does the treatment with TXA affect the risk of arterial thromboembolic events (ATE)?
Response/Recommendation
There is a paucity of randomized, clinical trials on the risk of ATE due to the administration of TXA intravenously, topically, and orally. However, the existing evidence does not suggest that TXA increases the risk of developing an ATE compared to placebo during the perioperative episode of a primary TJA.
Strength of Recommendation
Moderate.
Further Reading:
Eubanks JD. Antifibrinolytics in major orthopaedic surgery. J Am Acad Orthop Surg. 2010; 18: 132-138.
Gillette 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.
Whiting et al. Preliminary results suggest tranexamic acid is safe and effective in arthroplasty patients with severe comorbidities. Clin Orthop Relat Res. 2013 July 2.
