tranexamic for joints in CAD patients

[caligas]

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what are folks doing when ortho wants T.A. for joint replacment in pts with coronary disease, stents, etc?

 

[BLADEMDA]

what are folks doing when ortho wants T.A. for joint replacment in pts with coronary disease, stents, etc?

I encourage them to use Firbrin Spray instead. It is just as good.

http://www.ncbi.nlm.nih.gov/pubmed/17356139



http://www.ncbi.nlm.nih.gov/pubmed/21999623


INTERPRETATION:

We found that the use of tranexamic acid at induction, or topical fibrin spray intraoperatively, reduced blood loss compared to the control group. Blood loss was similar in the fibrin spray group and in the tranexamic acid group.

 

[BLADEMDA]

J Bone Joint Surg Am. 2012 Jul 3;94(13):1153-9.
Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis.

Yang ZG, Chen WP, Wu LD.
Source

Department of Orthopedic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, The People's Republic of China.

Abstract

BACKGROUND:

Total knee arthroplasty is associated with substantial blood loss and the risks of transfusion. Conflicting reports have been published regarding the effectiveness and safety of tranexamic acid in reducing postoperative blood loss in total knee arthroplasty. We performed a meta-analysis to investigate the effectiveness and safety of tranexamic acid in reducing postoperative blood loss in total knee arthroplasty.
METHODS:

A meta-analysis was performed to assess the effectiveness and safety of using tranexamic acid in total knee arthroplasty. Randomized controlled trials that had been published before May 2011 were retrieved, and fifteen studies met the inclusion criteria. The weighted mean difference in blood loss, number of transfusions per patient, prothrombin time, and postoperative activated partial thromboplastin time and the summary odds ratio of transfusion, deep-vein thrombosis, and pulmonary embolism were calculated in the group of patients who received tranexamic acid and the group of patients who received a placebo.
RESULTS:

The amount of blood loss and the number of blood transfusions per patient were significantly less and the proportion of patients who required a blood transfusion was smaller in the tranexamic acid group compared with the placebo group. No significant difference in prothrombin time, activated partial thromboplastin time, deep-vein thrombosis, and pulmonary embolism was detected between the tranexamic acid group and the placebo group.
CONCLUSIONS:

The meta-analysis shows that the use of tranexamic acid for patients undergoing total knee arthroplasty is effective and safe for the reduction of blood loss.

 

[BLADEMDA]

Another solution is to mix the TXA (3.0 gm) with 100 of NS solution and irrigate the wound site. This topical application of TXA works almost as well.


CONCLUSIONS:

At the conclusion of a total knee arthroplasty with cement, topical application of tranexamic acid directly into the surgical wound reduced postoperative bleeding by 20% to 25%, or 300 to 400 mL, resulting in 16% to 17% higher postoperative hemoglobin levels compared with placebo, with no clinically important increase in complications being identified in the treatment groups.


http://jbjs.org/data/Journals/JBJS/179/2503.pdf

 

[BLADEMDA]

Blood loss during TKA may be reduced through fibrin spray





McConnell JS. Knee. 2011. doi: 10.1016/j.knee.2011.06.004

• July 11, 2011

Fibrin spray is effective in the reduction of blood loss experienced during total knee arthroplasty, according to this study from investigators in the United Kingdom.
For this prospective, randomized controlled trial, the investigators categorized 66 elective cemented total knee arthroplasty patients into one of three treatment groups: those who received 10 mg/kg tranexamic acid given at the induction of anesthesia, those who received 10 ml of fibrin spray topically administered during surgery and those who received no treatment.
The authors reported no significant differences in blood loss between tranexamic acid and fibrin spray patients, and added they found a significant reduction in blood loss was achieved through use of fibrin spray when compared with their control group. The impact of tranexamic acid, they noted, was not significant

 

[BLADEMDA]

http://www.baxter.com/downloads/healthcare_professionals/products/Tisseel_PI.pdf

This product, Tisseel, contains Aprotinin. You must be aware of what the active compounds are in the fibrin sealant.

 

[BLADEMDA]

Hypersensitivity or allergic/anaphylactoid reactions may occur with the use of TISSEEL. Cases (<1/10,000) have

been reported in post marketing experience with Baxter's fibrin sealant

(see Adverse Reactions (6.2)). In specific

cases, these reactions have progressed to severe anaphylaxis. Such reactions may especially be seen if TISSEEL

is applied repeatedly over time or in the same setting, or if systemic aprotinin has been administered previously.

Even if the first treatment was well tolerated, this may not exclude the occurrence of an allergic reaction after a

subsequent administration of TISSEEL or systemic aprotinin. Observed symptoms of allergic anaphylactic reactions

to TISSEEL have included: bradycardia, tachycardia, hypotension, flushing, bronchospasm, wheezing, dyspnea,

nausea, urticaria, angioedema, pruritus, erythema and paresthesia. Such reactions may also occur in patients

receiving TISSEEL for the first time.

Aprotinin is included in TISSEEL for its antifibrinolytic properties. Aprotinin, a protein, is known to be associated

with anaphylactic reactions. Even in the case of strict local application of aprotinin, there is a risk of anaphylactic

reactions to aprotinin, particularly in the case of previous exposure

(see Contraindications (4.2)). TISSEEL does not

contain any substances of bovine origin.

Discontinue administration of TISSEEL in the event of hypersensitivity reactions. Mild reactions can be managed

with antihistamines. Severe hypotensive reactions require immediate intervention using current principles of shock

therapy. Remove remaining product from the application site.

 

[BLADEMDA]

Fibrin sealants have several advantages over older methods of hemostasis (stopping bleeding). They speed up the formation of a stable clot; they can be applied to very small blood vessels and to areas that are difficult to reach with conventional sutures; they reduce the amount of blood lost during surgery; they lower the risk of postoperative inflammation or infection; and they are conveniently absorbed by the body during the healing process. They are particularly useful for minimally invasive procedures and for treating patients with blood clotting disorders. Fibrin sealants are, however, being replaced for some specialized purposes by newer wound adhesives known as cyanoacrylates.


Description

All fibrin sealants in use as of 2003 have two major ingredients, purified fibrinogen (a protein) and purified thrombin (an enzyme) derived from human or bovine (cattle) blood. Many sealants have two additional ingredients, human blood factor XIII and a substance called aprotinin, which is derived from cows' lungs. Factor XIII is a compound that strengthens blood clots by forming cross-links between strands of fibrin. Aprotinin is a protein that inhibits the enzymes that break down blood clots.



Read more: Fibrin Sealants - test, blood, complications, time, infection, risk, rate, Definition, Purpose, Description, Preparation, Normal results http://www.surgeryencyclopedia.com/Ce-Fi/Fibrin-Sealants.html#ixzz27A3WnGtk

 

[Mman]

Is helping the body be even more pro-coagulant a good thing in patients with CAD? I'd rather transfuse a unit or two of pRBCs then increase their risk of in stent or in graft thrombosis.

 

[Planktonmd]

Tranexamic acid is mainly a Plasmin inhibitor, which means it protects fibrin clots that were already formed but it does not cause new clot formation.
Although it might enhance the platelets function a little it does not produce a hypercoagulable state.
So, I am not sure why it should be that scary in a patient with CAD???

 

[Mman]

So, I am not sure why it should be that scary in a patient with CAD???

Did anyone imply it was scary? Is transfusing a unit of blood scary? As with everything, think before you give and just make sure that the benefit you are providing to the patient is worth the risk.

 

[BLADEMDA]

Did anyone imply it was scary? Is transfusing a unit of blood scary? As with everything, think before you give and just make sure that the benefit you are providing to the patient is worth the risk.

That's why giving it at the site (whether TXA or Fibrin sealant) makes the most sense from a risk/benefit stand point.

 

[fakin' the funk]

what are folks doing when ortho wants T.A. for joint replacment in pts with coronary disease, stents, etc?

Umm...why are we considering methods to limit fibrinolysis and blood loss in cases with minimal blood loss that rarely require transfusion?

 

[BLADEMDA]

Umm...why are we considering methods to limit fibrinolysis and blood loss in cases with minimal blood loss that rarely require transfusion?

Revision total hip replacements can lose over a liter in blood loss. Yes, we use cell saver but it is better to avoid the blood loss rather than suction up the blood and give it back.

 

[Mman]

Umm...why are we considering methods to limit fibrinolysis and blood loss in cases with minimal blood loss that rarely require transfusion?

I don't think total knees "rarely require transfusion". I'd say they frequently require transfusion. It's just not in the OR that you are transfusing because the tourniquet is up. It's almost always POD 1 or 2 when they become anemic.



And I'd also agree that providing hemostasis at the site of an injury is likely to be far more beneficial.

 

[Arch Guillotti]

I don't think total knees "rarely require transfusion". I'd say they frequently require transfusion. It's just not in the OR that you are transfusing because the tourniquet is up. It's almost always POD 1 or 2 when they become anemic.



And I'd also agree that providing hemostasis at the site of an injury is likely to be far more beneficial.

I rarely transfuse for TKR's but there is always possibility of blood loss (especially redos) and I bet a at least a fewof them get transfused postop.

 

[Mman]

I rarely transfuse for TKR's but there is always possibility of blood loss (especially redos) and I bet a at least a fewof them get transfused postop.

nobody transfuses much for a total knee in the OR because of the tourniquet. The big blood loss is over the first 24-48 hours postop. They frequently get transfused on POD 1 or 2 at any hospital I've ever been at. From an anesthesia point of view, we don't know about it unless we go looking. I'd venture a guess that the majority of redo total knee's get transfused at some point postop, or if not a majority a significant percentage.

 

[Planktonmd]

Did anyone imply it was scary? Is transfusing a unit of blood scary? As with everything, think before you give and just make sure that the benefit you are providing to the patient is worth the risk.

What is the risk of giving Tranexamic acid?

 

[Planktonmd]

nobody transfuses much for a total knee in the OR because of the tourniquet. The big blood loss is over the first 24-48 hours postop. They frequently get transfused on POD 1 or 2 at any hospital I've ever been at. From an anesthesia point of view, we don't know about it unless we go looking. I'd venture a guess that the majority of redo total knee's get transfused at some point postop, or if not a majority a significant percentage.

Agree,
many of our total knee patients get transfused post-op

 

[anbuitachi]

7 years later. what is everyone doing? still no consensus as far as study is concerned. but in patients with cad with multiple stents >1 year ago, are people using TXA for TKR (not redo). or in patients with hx of CVA?

 

[coffeebythelake]

7 years later. what is everyone doing? still no consensus as far as study is concerned. but in patients with cad with multiple stents >1 year ago, are people using TXA for TKR (not redo). or in patients with hx of CVA?

P. J. Devereaux, J. Eikelboom, Insights into myocardial infarction after noncardiac surgery in patients with a prior coronary artery stent, BJA: British Journal of Anaesthesia, Volume 116, Issue 5, May 2016, Pages 584–586

Evidence from clinical trials suggests bleeding may be an important pathway causing MI and refutes the efficacy of anti-platelets to prevent perioperative MI. POISE-2 randomized 10 010 patients undergoing noncardiac surgery to perioperative aspirin or placebo. Aspirin did not prevent MI but increased the risk of major bleeding, and major bleeding was an independent predictor that patients would subsequently experience an MI.8 CRASH-2 randomized 20 211 trauma patients with, or at risk of, significant haemorrhage to tranexamic acid (an anti-fibrinolytic agent) or placebo. Tranexamic acid reduced all-cause mortality and bleeding mortality, and despite its anti-fibrinolytic actions, tranexamic acid reduced the risk of MI (Relative Risk, 0.64; 95% CI, 0.42–0.97).9 Moreover, in the CRASH-2 pre-specified subgroup of 13 273 patients who had traumatic bleeding and received tranexamic acid or placebo within three h of their injury, tranexamic acid reduced the risk of MI (Odds Ratio, 0.49; 95% CI, 0.30–0.81).10 Although evidence supports that some perioperative MIs in patients who have a coronary artery stent are as a result of thrombosis,11 the study by Wasowicz and colleagues suggests that a substantial proportion of these MIs are because of supply-demand mismatch from perioperative bleeding.

 

[coffeebythelake]

Despite the bravado with their title, it is far from conclusive. Lots of patients with different conditions lumped together

Whiting et al., 2014. Preliminary Results Suggest Tranexamic Acid is Safe and Effective in Arthroplasty Patients with Severe Comorbidities. Preliminary Results Suggest Tranexamic Acid is Safe and Effective in Arthroplasty Patients with Severe Comorbidities


This is a crap consensus statement from 2018 and why your orthopedic surgeon wants you to give TXA even in high risk patients with cardiac stents. Their consensus is that TXA is generally safe. Look at their rationale. They used ASA 3 as a proxy for high risk patients. Basically dilute the study population so no differences would be seen.



Tranexamic Acid Use in Total Joint Arthroplasty: The Clinical Practice Guidelines Endorsed by the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society
Fillingham, Yale A. et al. The Journal of Arthroplasty , Volume 33 , Issue 10 , 3065 - 3069

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 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

Rationale: Despite an established proposed mechanism of action for TXA as a fibrin clot stabilizer, clinician concerns remain over the use of any antifibrinolytic medication in patients considered at “high-risk” for thromboembolic events (e.g., previous history of VTE, MI with vascular stents, cerebral vascular occlusive disease) which continues to limit the widespread adoption of TXA use in hip and knee arthroplasty.13 Since no clinical trials have investigated specific risk factors, the American Society of Anesthesiologists (ASA) physical status classification system was used as a proxy to identify “high-risk” patients among the literature available. In a meta-regression analysis comparing a population of patients with greater than 50% ASA status ≥3 to another population with patients of greater than 50% ASA status 1 or 2, the results demonstrated no increase in the risk of VTE for patients undergoing a primary hip or knee arthroplasty.12 Due to the absence of experimental evidence, we also reviewed observational studies on the topic of TXA administration in patients with specific risk factors. Large database studies suggest TXA administration in patients with a history of VTE or ASA status of ≥ 3 does not experience an increased risk of VTE.14-17 In the “high-risk” patient population, we must consider the summation of the benefits and potential risks of administering TXA. Despite limited data on the safety of TXA, we wish to highlight a parallel lack of evidence for harm. Additionally, evidence has demonstrated that postoperative cardiovascular complications are associated with anemia and high blood transfusion rates.18-20 Therefore we wish to highlight the overall positive summation of data on TXA efficacy in the context of limited evidence for added risk with the use of TXA. In sum, the calculation of the number needed to harm for VTE among the total joint population was 983 patients, but the number needed to treated with IV TXA in THA and TKA to prevent a transfusion was only 4 and 3 patients, respectively.12 Although the available data limits for stronger advocacy and more widespread use in those at “high-risk”, each patient with known risks factors should be considered individually and we advocate for a multidisciplinary approach when deciding whether to withhold or administer TXA.

 

[coffeebythelake]

This seems to be a more balanced approach to looking at the subject.

P. J. Devereaux, J. Eikelboom, Insights into myocardial infarction after noncardiac surgery in patients with a prior coronary artery stent, BJA: British Journal of Anaesthesia, Volume 116, Issue 5, May 2016, Pages 584–586, Redirecting

Over the last decade an increasing amount of literature regarding the perioperative use of tranexamic acid (TXA) for bleeding control in orthopedic surgery has been published (1-6). While clinical trials found promising results regarding the reduction of blood loss and therefore a reduced rate of blood transfusions, concerns regarding prothrombotic adverse events including deep vein thrombosis, myocardial infarction, pulmonary embolism and cerebrovascular events have continued to dampen the enthusiasm and thus recommendations for wide spread use (7).

In clinical practice, this concern has thus lead to avoidance of the use of TXA in a large group of patients. Especially those with a history of coronary artery disease and stent-implantation or those having suffered a stroke are frequently considered to be potentially at increased risk for adverse events due the potential of TXA to promote clotting. These safety concerns are based on the inhibition of fibrinolysis and as a consequence the interference of TXA with the coagulation cascade. So far, there is a lack of clinical trials large enough to not only proof efficacy but also at the same time support the safety of TXA in this patient population. This dilemma is further complicated by the fact that the groups considered at risk for thromboembolic complications may be the same as those at increased risk for ischemic adversities in the setting of increased blood loss. Thus the question arises if in the setting of competing pathophysiologic mechanisms “at risk” patients could “in sum” benefit from the use of TXA, as anemia and higher blood transfusion rates are considered predictors for a worse cardiovascular outcome after surgery (8-10).

 

[coffeebythelake]

I think the answer is: no-one really knows if TXA is safe in cardiac stent patients. Does it increase the risk for instent thrombosis? And if it does how much higher risk? There are no good studies about this, and many existing studies specifically exclude patients with stents. Surgeons will opine that TXA is fine for everyone. Anesthesiologists will opine that it should be considered carefully in high risk patients.

As others have opined here in the forum, I would rather transfuse the patient a couple units than deal with thrombosis.

 

[coffeebythelake]

TXA does not increase risk of thrombosis in patients undergoing coronary artery surgery. Is it applicable for CAD stent patients with ortho surgery?

Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery
Myles et al., January 12, 2017
N Engl J Med 2017; 376:136-148
DOI: 10.1056/NEJMoa1606424

Among patients undergoing coronary-artery surgery, tranexamic acid was associated with a lower risk of bleeding than was placebo, without a higher risk of death or thrombotic complications within 30 days after surgery. Tranexamic acid was associated with a higher risk of postoperative seizures. (Funded by the Australian National Health and Medical Research Council and others; ATACAS Australia New Zealand Clinical Trials Registry number, ACTRN12605000557639.)

 

[anbuitachi]

TXA does not increase risk of thrombosis in patients undergoing coronary artery surgery. Is it applicable for CAD stent patients with ortho surgery?

Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery
Myles et al., January 12, 2017
N Engl J Med 2017; 376:136-148
DOI: 10.1056/NEJMoa1606424

Among patients undergoing coronary-artery surgery, tranexamic acid was associated with a lower risk of bleeding than was placebo, without a higher risk of death or thrombotic complications within 30 days after surgery. Tranexamic acid was associated with a higher risk of postoperative seizures. (Funded by the Australian National Health and Medical Research Council and others; ATACAS Australia New Zealand Clinical Trials Registry number, ACTRN12605000557639.)

i think there was a study that showed CVA was higher in TXA in valvular surgery

 

[ethilo]

Umm...why are we considering methods to limit fibrinolysis and blood loss in cases with minimal blood loss that rarely require transfusion?

I asked the same question to one of my attendings because I only saw like 150 mL EBL and thought the ortho guys were being a little silly. He told me to review the entire post op course of the knees and see what happens. I routinely do that now and I've noticed they usually have a HCT drop off about 9 by the end of the hospitalization even after our protocol of 1g TXA pre and post tourniquet intraop. Made me wonder what it was like before we started doing that intervention. I bet it was a lot more, especially with all that aggressive PT they do. Good eye opening exercise!

 

[coffeebythelake]

I asked the same question to one of my attendings because I only saw like 150 mL EBL and thought the ortho guys were being a little silly. He told me to review the entire post op course of the knees and see what happens. I routinely do that now and I've noticed they usually have a HCT drop off about 9 by the end of the hospitalization even after our protocol of 1g TXA pre and post tourniquet intraop. Made me wonder what it was like before we started doing that intervention. I bet it was a lot more, especially with all that aggressive PT they do. Good eye opening exercise!

Yeah, watch the 48hours postop CBC

 

[pgg]

TXA does not increase risk of thrombosis in patients undergoing coronary artery surgery. Is it applicable for CAD stent patients with ortho surgery?

Does this mean we should give 400 units per kilo of heparin to ortho patients before starting TXA? 🙂

 

[dchz]

It's late and i want to rant.

I think TXA is great! for fibrinolysis!!!

As @Planktonmd already stated, the MOA is to prevent clot breakdown. NOT to cause random bone bleeding to clot once you cut it.If the pt bled after a TKA, they need RBCs and surgical control of their bleeding.

List of things before I'd give myself before TXA if i had a TKA and i'm bleeding:

RBCs
Wholeblood
FFP
A better surgeon.
Aminocaproic ACID
.... ???
TXA

I think the literature behind TXA is a great case study on how we're failing to apply the scientific method. Some paper showed benefit in the group given TXA. But the paper does not show that there are tons of better things that can be done than getting fixated on TXA. TXA isn't a magic bullet to fix all the blood loss, but so many Ortho treat it as such. Same thing with the OB literature. We now carry TXA in our hemorrhage kit.... In bleeding OB patients, the issue is dilutional coagulopathy after uterine bleeding. TXA doesn't fix the fact that the patient bled 5 liters. And we KNOW the issue is the patient bled 5 liters. But we reach for the TXA to give the patient instead of blood or focus on uterine bleeding control??? WTF?

What if there was a paper comparing whole blood transfusion vs TXA? or hemostasis of bone/uterus vs TXA? or Aminocaproic Acid vs TXA?

/end rant

 

[DM27]

I have never been a large believer in the idea that ACA or TXA create some uber dangerous hypercoagulable milieu and have yet to find a well done study to even slightly support this perception.

On the other side of things, there are plenty of studies and meta-analyses of the use of TXA in pregnant women, a notoriously pro-coagulant population, with no significant changes in VTE events.

 

[anbuitachi]

I asked the same question to one of my attendings because I only saw like 150 mL EBL and thought the ortho guys were being a little silly. He told me to review the entire post op course of the knees and see what happens. I routinely do that now and I've noticed they usually have a HCT drop off about 9 by the end of the hospitalization even after our protocol of 1g TXA pre and post tourniquet intraop. Made me wonder what it was like before we started doing that intervention. I bet it was a lot more, especially with all that aggressive PT they do. Good eye opening exercise!

How does overall blood loss compare when no tourniquet is used?

Here the tourniquet comes down when the knee is closed. I was talking to a vascular surgeon once a long time ago in residency doing a bka . I wondered why they don't use tourniquets. The answer they gave me was you want to know what bleeds so you can stop it. If nothing bleeds you don't know what's bleeding and you can't intervene.


Also here the Ortho protocol is aspirin 325 bid postop toprevent dvt. Maybe that contributes to the bleeding poztopp

 

[Southpaw]

It's late and i want to rant.

I think TXA is great! for fibrinolysis!!!

As @Planktonmd already stated, the MOA is to prevent clot breakdown. NOT to cause random bone bleeding to clot once you cut it.If the pt bled after a TKA, they need RBCs and surgical control of their bleeding.

List of things before I'd give myself before TXA if i had a TKA and i'm bleeding:

RBCs
Wholeblood
FFP
A better surgeon.
Aminocaproic ACID
.... ???
TXA

I think the literature behind TXA is a great case study on how we're failing to apply the scientific method. Some paper showed benefit in the group given TXA. But the paper does not show that there are tons of better things that can be done than getting fixated on TXA. TXA isn't a magic bullet to fix all the blood loss, but so many Ortho treat it as such. Same thing with the OB literature. We now carry TXA in our hemorrhage kit.... In bleeding OB patients, the issue is dilutional coagulopathy after uterine bleeding. TXA doesn't fix the fact that the patient bled 5 liters. And we KNOW the issue is the patient bled 5 liters. But we reach for the TXA to give the patient instead of blood or focus on uterine bleeding control??? WTF?

What if there was a paper comparing whole blood transfusion vs TXA? or hemostasis of bone/uterus vs TXA? or Aminocaproic Acid vs TXA?

/end rant

So I've never seen an ortho surgeon do a TKA without a tourniquet. I imagine there's a reason for this. I personally don't want to sit and watch them cauterize for 2 hours for a case that should be door to door in 60-90 minutes. The routine use of TXA, whether topical or IV, has basically eliminated transfusion for patients having joint surgery post-operatively. This is a good thing. I can't think of a reason other than 'we're so pretty and smart...' that we'd even lift a finger in disagreement with them on this one. Your list of things you want to give before TXA is ridiculous.

 

[dchz]

So I've never seen an ortho surgeon do a TKA without a tourniquet.

So how is the TXA getting to the site of action?

The routine use of TXA, whether topical or IV, has basically eliminated transfusion for patients having joint surgery post-operatively.

What? May be I'm crazy, but please show your source on this.

 

[Southpaw]

So how is the TXA getting to the site of action?

Given pre tourniquet inflation or topically at the site.

What? May be I'm crazy, but please show your source on this.

You’re in training. This is news to you?

 

[dchz]

You’re in training. This is news to you?

Humor my ignorance and show me the source?

 

[Southpaw]

Humor my ignorance and show me the source?

https://www.aaos.org/uploadedFiles/...lines_and_Reviews/TXA-Clinical-Guidelines.pdf

 

[Planktonmd]

Plasmin inhibitors theoretically sound helpful in decreasing transfusion requirements but the evidence in their favor is at best shaky. On the other hand there is no evidence that they are harmful even in patients with CAD and DES. So IMHO if your Orthopod had recently discovered plasmin inhibitors, and his buddies told him that they use them everyday, and now he is demanding that you use them... I say, from a political point of view, you probably should accommodate him.

 

[dchz]

https://www.aaos.org/uploadedFiles/...lines_and_Reviews/TXA-Clinical-Guidelines.pdf

I guess I am still in training. To be honest I hope i'm never out of training enough to take that hogwash as gospel.

Plasmin inhibitors theoretically sound helpful in decreasing transfusion requirements but the evidence in their favor is at best shaky. On the other hand there is no evidence that they are harmful even in patients with CAD and DES. So IMHO if your Orthopod had recently discovered plasmin inhibitors, and his buddies told him that they use them everyday, and now he is demanding that you use them... I say, from a political point of view, you probably should accommodate him.

Yep. Totally agree. But one should know that it's a political move and not be a bad scientist and think you're curing surgical blood loss with a magical bullet.

 

[Southpaw]

I guess I am still in training. To be honest I hope i'm never out of training enough to take that hogwash as gospel.



Yep. Totally agree. But one should know that it's a political move and not be a bad scientist and think you're curing surgical blood loss with a magical bullet.

Sounds good. Keep telling your surgeons to go without the tourniquet while you transfuse whole blood.

 

[nimbus]

I guess I am still in training. To be honest I hope i'm never out of training enough to take that hogwash as gospel.



Yep. Totally agree. But one should know that it's a political move and not be a bad scientist and think you're curing surgical blood loss with a magical bullet.

You asked @Southpaw for a reference and he gave it to you. An appropriate reply would be “thank you”. Why do you call it hogwash? The recommendations are reasonable based on the information we have at this time.

 

[vector2]

I guess I am still in training. To be honest I hope i'm never out of training enough to take that hogwash as gospel.



Yep. Totally agree. But one should know that it's a political move and not be a bad scientist and think you're curing surgical blood loss with a magical bullet.

Are you just picking a bone with how southpaw phrased his statement about TXA basically eliminating transfusion? Maybe it's a bit of an exaggeration to say that transfusion no longer exists with TXA, but that clinical guideline cites meta-analyses with thousands of patients showing that TXA significantly reduces if not eliminates (in some cases) the risk of prbc transfusion. The efficacy of TXA be it IV or topical is not up for the debate given the weight of the current evidence...

 

[Southpaw]

Hip revisions aside, and with a few exceptions of cases gone bad, I have not seen an elective THA/TKA get transfused in the 5+ years I’ve been an attending (all with topical or IV TXA). In residency (pre-TXA) it was fairly routine for THAs and the occasional TKA to get transfused post-op.

A resident showed clear lack of understanding of the role of TXA in joint arthroplasty. He’d rather expose a patient to transfusion than give TXA. There’s no question TXA has made a huge improvement in the care we provide our patients. It’s not up for debate. There are good, recent guidelines showing this from the ortho societies that ASRA added their name to.

@dchz if you truly want to avoid the Dunning-Kruger you’ll have to work much harder than you have here. I’m trying to not be overly critical of you here as I realize you’re in training but when you show clear lack of understanding of an issue you could at least show enough motivation to do some googling yourself rather than have me spoonfeed you the very recent guidelines.

 

[anbuitachi]

i think the issue here is txa in sick patients, CAD 5 stents in past 10 years. on aspirin for the Total knee/hip.
Or CVA w hemiparesis.

 

[Southpaw]

i think the issue here is txa in sick patients, CAD 5 stents in past 10 years. on aspirin for the Total knee/hip.
Or CVA w hemiparesis.

It’s a worthwhile question and one that’d be difficult to answer completely. I don’t envision any sort of RCT to answer the question for us. If you don’t feel comfortable giving high risk patients TXA then you put that patient at risk with everything involved in a transfusion. Not the end of the world of course, but the patient will get anemic, maybe some degree of hemodynamic instability, and importantly may not feel up to recovering post operatively as needed to ensure good recovery from the new joint which is why the patient is there to begin with.

The new guidelines state topical is as efficacious as IV, with measured blood levels respectable relative to IV. Importantly, topical admin shows extremely reduced rates of blood transfusion also. So if you aren’t comfortable giving it IV at least encourage the surgeon to give it topically.

 

[GaseousClay]

It’s a worthwhile question and one that’d be difficult to answer completely. I don’t envision any sort of RCT to answer the question for us. If you don’t feel comfortable giving high risk patients TXA then you put that patient at risk with everything involved in a transfusion. Not the end of the world of course, but the patient will get anemic, maybe some degree of hemodynamic instability, and importantly may not feel up to recovering post operatively as needed to ensure good recovery from the new joint which is why the patient is there to begin with.

The new guidelines state topical is as efficacious as IV, with measured blood levels respectable relative to IV. Importantly, topical admin shows extremely reduced rates of blood transfusion also. So if you aren’t comfortable giving it IV at least encourage the surgeon to give it topically.

If measure blood levels of TXA is the same topical or IV then wouldn't it theoretically be the same risk? In that case why give topical over IV just give it.

 

[anbuitachi]

was curious about blood loss so i looked back in the record for patient i didn't give txa to. hct dropped about 5 points from preop, which is ok. interesting to know from above posters that knees bleed like crazy postop, i'll do longer followups now to take a look

 

[deleted162650]

2 of our orthopods will only put the tourniquet up for cementing (8 min tourniquet times). One of them is who I would consider our best joint guy. Yes the case takes a little longer and intraop EBL is higher (like 150-200mL). But, there’s good evidence to show less post-op bleeding and lower infection rates. If I was having a TKA tomorrow, that’s what I’d want. And go ahead and top me off with TXA while you’re at it.

 

[anbuitachi]

2 of our orthopods will only put the tourniquet up for cementing (8 min tourniquet times). One of them is who I would consider our best joint guy. Yes the case takes a little longer and intraop EBL is higher (like 150-200mL). But, there’s good evidence to show less post-op bleeding and lower infection rates. If I was having a TKA tomorrow, that’s what I’d want. And go ahead and top me off with TXA while you’re at it.

whats their reason for this?

 

[Hork Bajir]

Apparently even a small amount of hemodynamically insignificant bleeding into the joint capsule can cause a great deal of the postop pain. One surgeon I work with leaves drains in knees after just about any (inpatient) procedure for that reason, regardless of any special concern about postop bleeding.