A rationale for universal tranexamic acid in major joint arthroplasty: overall efficacy and impact of risk factors for transfusion

Authors

Katerina Pavenski, Saint Michael's Hospital University of Toronto
Sarah E. Ward, Saint Michael's Hospital University of Toronto
Gregory M.T. Hare, Saint Michael's Hospital University of Toronto
John Freedman, Saint Michael's Hospital University of Toronto
Robisa Pulendrarajah, Saint Michael's Hospital University of Toronto
Razak A. Pirani, Saint Michael's Hospital University of Toronto
Nicholas Sheppard, Saint Michael's Hospital University of Toronto
Colm Vance, Saint Michael's Hospital University of Toronto
Alexander White, Saint Michael's Hospital University of Toronto
Nick Lo, Saint Michael's Hospital University of Toronto
James P. Waddell, Saint Michael's Hospital University of Toronto
Alex Ho, Saint Michael's Hospital University of Toronto
Emil H. Schemitsch, Saint Michael's Hospital University of Toronto
Mark Kataoka, Saint Michael's Hospital University of Toronto
Earl R. Bogoch, Saint Michael's Hospital University of Toronto
Kiran Saini, Saint Michael's Hospital University of Toronto
C. David Mazer, Saint Michael's Hospital University of Toronto
James E. Baker, Saint Michael's Hospital University of Toronto

Document Type

Article

Publication Date

1-1-2019

Journal

Transfusion

Volume

59

Issue

1

First Page

207

Last Page

216

URL with Digital Object Identifier

10.1111/trf.14995

Abstract

© 2018 AABB BACKGROUND: Tranexamic acid (TXA) therapy is effective in reducing postoperative red blood cell (RBC) transfusion in total joint arthroplasty (TJA), yet uncertainty persists regarding comparative efficacy and safety among specific patient subgroups. We assessed the impact of a universal TXA protocol on RBC transfusion, postoperative hemoglobin (Hb), and adverse outcomes to determine whether TXA is safe and effective in TJA, both overall and in clinically relevant subgroups. STUDY DESIGN AND METHODS: A retrospective observational study was performed on patients undergoing TJA at our institution spanning 1 year before and after the implementation of a universal protocol to administer intravenous (IV) TXA. The primary outcome was percentage of patients transfused, and secondary outcomes were perioperative Hb and occurrence of adverse events (death, myocardial infarction, stroke, seizure, pulmonary embolism, deep vein thrombosis, and acute kidney injury). Outcomes were compared in pre- and post-protocol groups with χ 2 analysis. Logistic regression compared risk of transfusion in pre- and post-protocol subgroups of patients with differing risk for transfusion (anemia, body mass index [BMI], and sex). RESULTS: No differences were found in baseline patient characteristics across pre- and post-protocol groups (n = 1084 and 912, respectively). TXA use increased from 32.3% to 92.2% while transfusion rates decreased from 10.3% to 4.8% (p < 0.001). Postoperative Day 3 Hb increased from 95.8 to 101.4 g/L (p < 0.001). Logistic regression demonstrated reduced transfusion in post-protocol subgroups regardless of sex, anemia, or BMI (p < 0.001). No increase in adverse events was observed (p = 0.8451). CONCLUSIONS: Universal TXA was associated with a reduction of RBC transfusion, overall and in clinically relevant subgroups, strengthening the rationale for universal therapy.