The Use of Tranexamic Acid to Decrease Perioperative Blood Loss Following a
Carroll KM, Newman JM and Cross MB*
Assistant Attending Orthopaedic Surgeon, Hospital for Special Surgery New York, USA
- *Corresponding Author:
- Michael B. Cross, MD
Assistant Attending Orthopaedic Surgeon
Hospital for Special Surgery
535 E. 70th St, New York, NY 10021
Tel: (917) 484-2024
E-mail: [email protected]
Received Date: July 03, 2014; Accepted Date: July 16, 2014; Published Date: July 22, 2014
Citation: Carroll KM, Newman JM and Cross MB (2014) The Use of Tranexamic Acid to Decrease Perioperative Blood Loss Following a TKA. Orthopedic Muscul Syst 3: 160. doi: 10.4172/2161-0533.1000160
Copyright: © 2014 Carroll KM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Visit for more related articles at Orthopedic & Muscular System: Current Research
Perioperative blood loss during total knee arthroplasty can be significant; in fact, post-operative blood loss following a total knee arthroplasty (TKA) has been reported to range from 500 to 1000 mL [1-4]. Historically, allogenic transfusions were the standard method of managing acute blood loss after TKA; however, due to the published risks associated with transfusions including transfusion reactions [1,5] and the high cost, [6,7] surgeons are trying to find an alternative method to better manage blood loss following a TKA.
Tranexamic acid (TXA) is a pharmacological agent that reduces the conversion of plasminogen to plasmin, an enzyme that degrades fibrin clots, fibrinogen and other plasma proteins . TXA provides an inexpensive synthetic antifibrinolytic agent that has been demonstrated to be effective in multiple surgical procedures . For one, TXA has been shown to significantly reduce post-operative blood loss following TKA and can be safely administered both intravenously (IV) with a single or double dose and topically with no increased risk of thromboembolic events [4,7,10-19]. The cost of 1 g of tranexamic acid is approximately $58; however, the decrease in transfusion rates using TXA leads to a significant decrease in cost per patient [6,7,11].
While the current literature has reported the success and safety of tranexamic acid, no consensus dosing schedule, timing or route of administration method has been established. The current contraindications to giving the drug IV include cardiac disease, renal or hepatic disease, and a previous embolic event, while no current contraindication exists for the topical administration . If giving IV, some literature also suggests it should be given as two doses with one preoperatively or post-operatively and one dose 5 min prior to deflation of the tourniquet [20,21]; yet other studies state it can be given effectively at the start of the procedure [1,22,23]. In a meta-analysis of 7 studies analyzing topical TXA in primary TKA, the dose of topical tranexamic acid ranged from 250 mg to 3 g in 5 ml to 100 ml of saline , whereas IV dosages range from a single or double dose of either 1 g, 2 g or 3 g of tranexamic acid .
The use of pharmacologics has long been underappreciated in orthopedics; however, the use of tranexamic acid during total knee arthroplasty is becoming an emerging standard of care. For the orthopaedic surgeon, the take home message is it works regardless of how you dose it or how you administer it; while future studies need to establish consensus in the orthopaedic community as to how it is best delivered, surgeons can now use the drug with confidence, as it is cheap and effective at reducing blood loss after TKA.
- Tanaka N, Sakahashi H, Sato E, Hirose K, Ishima T, et al. (2001) Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. J Bone Joint Surg Br 83: 702-705.
- Sehat KR, Evans RL, Newman JH (2004) Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br 86: 561-565.
- Sehat KR, Evans R, Newman JH (2000) How much blood is really lost in total knee arthroplasty?. Correct blood loss management should take hidden loss into account. Knee 7: 151-155.
- Good L, Peterson E, Lisander B (2003) Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth 90: 596-599.
- Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, et al. (1999) An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 81: 2-10.
- Tuttle JR, Ritterman SA, Cassidy DB, Anazonwu WA, Froehlich JA, et al. (2014) Cost Benefit Analysis of Topical Tranexamic Acid in Primary Total Hip and Knee Arthroplasty. J Arthroplasty.
- Gillette BP, MaraditKremers H, Duncan CM, Smith HM, Trousdale RT, et al. (2013) Economic impact of tranexamic acid in healthy patients undergoing primary total hip and knee arthroplasty. J Arthroplasty 28: 137-139.
- Sharma V, Fan J, Jerath A, Pang KS, Bojko B, et al. (2012) Pharmacokinetics of tranexamic acid in patients undergoing cardiac surgery with use of cardiopulmonary bypass. Anaesthesia 67: 1242-1250.
- Ker K, Edwards P, Perel P, Shakur H, Roberts I (2012) Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ 344: e3054.
- Vigna-Taglianti F, Basso L, Rolfo P, Brambilla R, Vaccari F, et al. (2014) Tranexamic acid for reducing blood transfusions in arthroplasty interventions: a cost-effective practice. Eur J OrthopSurgTraumatol 24: 545-551.
- Lin PC, Hsu CH, Huang CC, Chen WS, Wang JW (2012) The blood-saving effect of tranexamic acid in minimally invasive total knee replacement: is an additional pre-operative injection effective? J Bone Joint Surg Br 94: 932-936.
- Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, et al. (2011) Tranexamic acid in total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg Br 93: 1577-1585.
- Pachauri A, Acharya KK, Tiwari AK (2013) The Effect of Tranexamic Acid on Hemoglobin Levels During Total Knee Arthroplasty. Am J Ther .
- Wong J, Abrishami A, El Beheiry H, Mahomed NN, Roderick Davey J, et al. (2010) Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg Am 92: 2503-2513.
- Wind TC, Barfield WR, Moskal JT (2013) The effect of tranexamic acid on blood loss and transfusion rate in primary total knee arthroplasty. J Arthroplasty 28: 1080-1083.
- Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, et al. (2014) The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J OrthopSurg Res 9: 13.
- Hiippala ST, Strid LJ, Wennerstrand MI, Arvela JV, Niemelä HM, et al. (1997) Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. AnesthAnalg 84: 839-844.
- Benoni G, Lethagen S, Fredin H (1997) The effect of tranexamic acid on local and plasma fibrinolysis during total knee arthroplasty. Thromb Res 85: 195-206.
- Cid J, Lozano M (2005) Tranexamic acid reduces allogeneic red cell transfusions in patients undergoing total knee arthroplasty: results of a meta-analysis of randomized controlled trials. Transfusion 45: 1302-1307.
- Yang ZG, Chen WP, Wu LD (2012) Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis. J Bone Joint Surg Am 94: 1153-1159.
- Maniar RN, Kumar G, Singhi T, Nayak RM, Maniar PR (2012) Most effective regimen of tranexamic acid in knee arthroplasty: a prospective randomized controlled study in 240 patients. ClinOrthopRelat Res 470: 2605-2612.
- Ortega-Andreu M, Perez-Chrzanowska H, Figueredo R, Gomez-Barena E (2011) Blood loss control with two doses of tranexamic acid in multimodal protocol for total knee arthroplasty. Open Orthop J 5: 44-48.
- Jansen AJ, Andreica S, Claeys M, D'Haese J, Camu F, et al. (1999) Use of tranexamic acid for an effective blood conservation strategy after total knee arthroplasty. Br J Anaesth 83: 596-601.
- Panteli M, Papakostidis C, Dahabreh Z, Giannoudis PV (2013) Topical tranexamic acid in total knee replacement: a systematic review and meta-analysis. Knee 20: 300-309.