Temporary clamping of drain combined with tranexamic acid reduce blood loss after total knee arthroplasty: a prospective randomized controlled trial.
ABSTRACT: Total knee arthroplasty (TKA) is associated with a significant blood loss. Several methods have been reported to reduce postoperative blood loss and avoid homologous blood transfusions. In this study, we investigated the efficacy of temporary clamping of the drain either or not in combination with tranexamic acid administration for controlling blood loss after TKA.The prospective, randomized, and double-blinded study was conducted in our institute. Total of 240 patients, who diagnosed primary osteoarthritis and scheduled to undergo a primary TKA,,were randomized into one of the four groups: Group A or control group, the drain was not clamped and the patient received a placebo; Group B, the drain was not clamped and the patient received tranexamic acid; Group C, the drain was clamped and the patient received a placebo; and Group D, the drain was clamped and the patient received tranexamic acid. The volume of drained blood at 48 hours postoperatively, the decreasing of hemoglobin (Hb) level at 12 hours postoperatively and the number of patients requiring blood transfusion were recorded and compared.The mean postoperative volumes of drained blood and the amount of blood transfusion in the three study groups (group B, C and D) were significantly lower than those in the control group (p?
Project description:<h4>Background</h4>Many studies have investigated the effect of tourniquet release time and closed suction drainage in total knee arthroplasty (TKA). However, controversy remains as to the advisability of preclosure tourniquet release and the advisability of closed suction drain use following total knee arthroplasty.<h4>Questions/purposes</h4>The aim of the study was to investigate if there is a benefit of performing tourniquet release after skin closure, along with drain clamping, for the first 6h following TKA.<h4>Methods</h4>Ninety-six patients underwent TKA between May 2009 and April 2010. Fourteen of these were excluded because of systemic diseases and simultaneous bilateral TKA. Twenty-nine of these were excluded due to use of a patellar component and posterior cruciate ligament (PCL)-sacrificing systems. Thus, 53 patients that underwent PCL-retaining cemented TKA were reviewed retrospectively. In the control group (group C), the tourniquet was released before skin closure, an attempt at hemostasis was made, and a compressive bandage was applied. The drain was not clamped in these patients. The test group of 23 patients (group T) had tourniquet release after skin closure and after the compressive bandage was applied. The drain was clamped for the first 6h after surgery. The two groups were compared as to the amount of drained blood, postoperative change in hemoglobin, postoperative complications, and knee function.<h4>Results</h4>We found that drained blood and hemoglobin drop were significantly lower in group T compared with group C. There was no difference regarding postoperative complications and knee function.<h4>Conclusion</h4>We conclude that tourniquet release after skin closure and compressive dressing followed by 6h of drain clamping reduces postoperative blood loss in TKR surgery.
Project description:<h4>Introduction</h4>The use of closed-suction drainage systems after total knee arthroplasty (TKA) is common practice in India, but with no consensus on its use. In this retrospective study, we compared whether clamped or unclamped drainage has any advantages over the other in unilateral TKA.<h4>Methods</h4>Group-A (n?=?351) had an unclamped drain removed at 24?h postoperative, with measurement of total drainage at 24?h between January 2011 and February 2013. Group B (n?=?349) had drains kept for a total of 8?h-clamped for the first 4?h and unclamped for a further 4, between March 2013 to September 2016. Drainage volume, as well as the hemodynamic markers-hemoglobin (Hb) drop, transfusion rate were evaluated.<h4>Results</h4>Mean drain output in Group- A was significantly higher than Group- B (215.64?ml versus 28.34?ml). The postoperative Hb was significantly higher in Group-B (11.46?g/dl versus 10.57?g/dl). Mean Hb drop was significantly higher in Group A (2.16??g/dl versus 1.18?g/dl). The transfusion rates were lower in Group-B, though not statistically significant.<h4>Conclusions</h4>The 4- hour clamping method effectively reduces drain output and fall in hemoglobin. For those who continue using closed suction drains, clamping could prove to be an effective way of reducing post-operative blood loss and the need for transfusions.
Project description:Recently, a number of studies using intra-articular application of tranexamic acid (IA-TXA), with different dosage and techniques, successfully reduced postoperative blood loss in total knee replacement (TKR). However, best of our knowledge, the very low dose of IA-TXA with drain clamping technique in conventional TKR has not been yet studied. This study aimed to evaluate the effectiveness and dose-response effect of two low-dose IA-TXA regimens in conventional TKR on blood loss and blood transfusion reduction.Between 2010 and 2011, a triple-blinded randomized controlled study was conducted in 135 patients undergoing conventional TKR. The patients were allocated into three groups according to intra-articular solution received: Control group (physiologic saline), TXA-250 group (TXA 250 mg), and TXA-500 group (TXA 500 mg). The solution was injected after wound closure followed by drain clamping for 2 hours. Blood loss and transfusion were recorded. Duplex ultrasound was performed. Functional outcome and complication were followed for one year.There were forty-five patients per groups. The mean total hemoglobin loss was 2.9 g/dL in control group compared with 2.2 g/dL in both TXA groups (p?>?0.001). Ten patients (22%, control), six patients (13%, TXA-250) and none (TXA-500) required transfusion (p?=?0.005). Thromboembolic events were detected in 7 patients (4 controls, 1 TXA-250, and 2 TXA-500). Functional outcome was non-significant difference between groups.Combined low-dose IA-TXA, as 500 mg, with 2-hour clamp drain is effective for reducing postoperative blood loss and transfusion in conventional TKR without significant difference in postoperative knee function or complication.ClinicalTrials.gov NCT01850394.
Project description:OBJECTIVE:This study aimed to compare the effects of intravenous, topical and combined routes of tranexamic acid (TXA) administration on blood loss and transfusion requirements in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). DESIGN:This was a meta-analysis of randomised controlled trials (RCT) wherein the weighted mean difference (WMD) and relative risk (RR) were used for data synthesis applied in the random effects model. Stratified analyses based on the surgery type, region, intravenous and topical TXA dose and transfusion protocol were also conducted. The main outcomes included intraoperative and total blood loss volume, transfusion rate, low postoperative haemoglobin (Hb) level and postoperative Hb decline. However, the secondary outcomes included length of hospital stay (LOS) and/or occurrence of venous thromboembolism (VTE). SETTING:We searched the PubMed, Embase and Cochrane CENTRAL databases for RCTs that compared different routes of TXA administration. PARTICIPANTS:Patients undergoing TKA or THA. INTERVENTIONS:Intravenous, topical or combined intravenous and topical TXA. RESULTS:Twenty-six RCTs were selected, and the intravenous route did not differ substantially from the topical route with respect to the total blood loss volume (WMD=30.92, p=0.31), drain blood loss (WMD=-34.53, p=0.50), postoperative Hb levels (WMD=-0.01, p=0.96), Hb decline (WMD=-0.39, p=0.08), LOS (WMD=0.15, p=0.38), transfusion rate (RR=1.08, p=0.75) and VTE occurrence (RR=1.89, p=0.15). Compared with the combined-delivery group, the single-route group had significantly increased total blood loss volume (WMD=198.07, p<0.05), greater Hb decline (WMD=0.56, p<0.05) and higher transfusion rates (RR=2.51, p<0.05). However, no significant difference was noted in the drain blood loss, postoperative Hb levels and VTE events between the two groups. The intravenous and topical routes had comparable efficacy and safety profiles. CONCLUSIONS:The combination of intravenous and topical TXA was relatively more effective in controlling bleeding without increased risk of VTE.
Project description:Studies on the use of tranexamic acid (TXA) to improve clinical outcomes after joint arthroplasty have reported contrasting results between intravenous (IV) TXA alone and combined IV and intraarticular (IA) administration. We compared the effectiveness of the 2 methods in providing higher postoperative hemoglobin (Hb) levels in patients undergoing primary total knee arthroplasty (TKA).A total of 100 TKA patients were randomly assigned to receive either IV TXA alone (group 1) or combined IV and topical IA TXA (group 2). Hb and hematocrit levels were measured before and after surgery. The amount of drained blood and transfused blood for the 2 groups was compared.The Hb level was significantly higher at postoperative day 4, together with a positive, albeit not significant, trend toward less postoperative blood loss in the group that received combined IV and IA TXA. No postoperative infections or deep venous thrombosis events occurred.This study reinforces evidence that, as compared to IV TXA alone, combined IV and IA administration of TXA has a synergic effect, leading to higher postoperative Hb levels without influencing drug safety in TKA patients.
Project description:Endoprosthetic surgery can lead to relevant blood loss resulting in red blood cell (RBC) transfusions. This study aimed to identify risk factors for blood loss and RBC transfusion that enable the prediction of an individualized transfusion probability to guide preoperative RBC provision and blood saving programs. A retrospective analysis of patients who underwent primary hip or knee arthroplasty was performed. Risk factors for blood loss and transfusions were identified and transfusion probabilities computed. The number needed to treat (NNT) of a potential correction of preoperative anemia with iron substitution for the prevention of RBC transfusion was calculated. A total of 308 patients were included, of whom 12 (3.9%) received RBC transfusions. Factors influencing the maximum hemoglobin drop were the use of drain, tranexamic acid, duration of surgery, anticoagulation, BMI, ASA status and mechanical heart valves. In multivariate analysis, the use of a drain, low preoperative Hb and mechanical heart valves were predictors for RBC transfusions. The transfusion probability of patients with a hemoglobin of 9.0-10.0 g/dL, 10.0-11.0 g/dL, 11.0-12.0 g/dL and 12.0-13.0 g/dL was 100%, 33.3%, 10% and 5.6%, and the NNT 1.5, 4.3, 22.7 and 17.3, while it was 100%, 50%, 25% and 14.3% with a NNT of 2.0, 4.0, 9.3 and 7.0 in patients with a drain, respectively. Preoperative anemia and the insertion of drains are more predictive for RBC transfusions than the use of tranexamic acid. Based on this, a personalized transfusion probability can be computed, that may help to identify patients who could benefit from blood saving programs.
Project description:<h4>Background</h4>Blood transfusion rates after total knee arthroplasty (TKA) in patients without hemophilia have diminished with the use of a standardized multimodal blood loss prevention method (MBLPM) that includes intra-articular tranexamic acid (TXA) (MBLPM-TXA). However, the topic has not been addressed in people with hemophilia.<h4>Questions/purposes</h4>Our aim was to investigate whether the MBLPM-TXA prevents blood loss in patients with hemophilia A who undergo TKA, thereby decreasing the need for post-operative blood transfusion.<h4>Methods</h4>This retrospective case-control comparative study involved 30 TKA patients who had a severe degree of hemophilia A without inhibitions: one group treated with the MBLPM-TXA (<i>n</i> = 15) and a second group treated without it (<i>n</i> = 15). In all cases, the pre-operative hemoglobin level was greater than 13 g/dL.<h4>Results</h4>The MBLPM-TXA group had a transfusion rate of zero, whereas 46.6% of the patients (seven of 15) in the non-MBLPM-TXA group needed transfusion.<h4>Conclusion</h4>This retrospective case-control study showed that the use of an MBLPM-TXA in patients with hemophilia A who underwent TKA was effective in reducing rates of transfusion. We recommend its use.
Project description:Intravenous tranexamic acid (IV TXA) is one of the most effective agents in use for reducing blood loss following total knee arthroplasty (TKA) but its safety regarding venous thromboembolic events (VTEs) remains in question. The direct, local application of TXA may reduce systemic toxicity whilst maintaining good or better bleeding control compared to IV TXA. The topical application of TXA via Hemovac drains has been reported previously with good results. However, there are no data on peri-articular TXA injections during TKA.We conducted an open randomized, pilot study of peri-articular vs. IV TXA in 60 patients undergoing TKA. 30 patients received either: (i) 750 mg peri-articular TXA into the medial, lateral capsules and the quadriceps tendon prior to capsular closure and tourniquet deflation (group1), or (ii) 750 mg of IV TXA just before tourniquet deflation. Blood loss in the hemovac drain and hemoglobin (Hb) concentrations were measured at 24 and 48 h (h), and the number of blood transfusions and leg circumference measurements were recorded.At 48 h, the total blood loss in the hemovac drain was 445 mL in group 1 vs. 520 mL in group 2 (p?=?0.081) and the corresponding declines in Hb were 1.85 g/dL vs. 1.87 g/dL (p?=?0.84). 16 patients received blood transfusions: 9 vs. 7 in groups 1 and 2, respectively (p?=?0.928). There were no differences in thigh and lower leg circumferences, pain scores, knee flexion at discharge date and lengths of hospital stay. There were no clinically detected venous thromboembolic events.This pilot study has shown promising results for peri-articular TXA during TKA. Additional, larger studies are needed to confirm our results and be powered to show differences in efficacy and safety of peri-articular vs. IV TXA.ClinicalTrials.gov Identifier NCT02829346 . Retrospectively registered: 07/11/2016.
Project description:OBJECTIVE:Tranexamic acid (TXA) and the hemostatic agent Floseal® have already been used to minimize bleeding during total knee arthroplasty (TKA). METHODS:We conducted a prospective, randomized study of 90 patients with indications for TKA. Following inclusion, the participants were randomly allocated in blocks to the following 3 groups: control, Floseal® and TXA. Bleeding parameters, including decreases in hemoglobin (Hb), drain output, number of blood transfusions and complications, were assessed. ClinicalTrials.gov: NCT02152917. RESULTS:The mean decrease in Hb was highest in the control group (4.81±1.09 g/dL), followed by the Floseal® (3.5±1.03 g/dL) and TXA (3.03±1.2 g/dL) groups. The Floseal® and TXA groups did not differ, and both performed better than the control group. The mean total drain output was 901.3±695.7 mL in the control group, 546.5±543.5 mL in the TXA group and 331.2±278.7 mL in the Floseal® group. Both TXA and Floseal® had significantly less output than the control group, and Floseal® had significantly less output than TXA. The number of blood transfusions was very small in all 3 groups. CONCLUSION:The use of TXA or Floseal® was associated with less blood loss than that of the control group among patients undergoing primary TKA, as measured both directly (intraoperative bleeding + drainage) and on the basis of a decrease in Hb, without differences in the rate of complications. TXA and Floseal® showed similar decreases in Hb and total measured blood loss, but the drain output was smaller in the Floseal® group.
Project description:<h4>Background</h4>There is no consensus on how tourniquet and tranexamic acid (TXA) use in total knee arthroplasty (TKA) affect blood transfusion rates and total blood loss. We compared outcome measures and transfusion rates after TKA, with and without the use of tourniquet and TXA.<h4>Methods</h4>A retrospective study of 477 consecutive patients undergoing primary TKA between 2008 and 2013 was performed. There were 243 in the tourniquet-assisted (TA) and 234 in the tourniquet-unassisted (TU) group. Operative times, hemoglobin levels, blood transfusion rates, complications, and length of stay were assessed. Subanalysis was performed on those patients receiving and not receiving TXA within the TU group.<h4>Results</h4>Mean operative duration was 66.4 minutes in the TA group and 87.5 minutes in the TU group (<i>P</i> < .0001). Mean postoperative drop in hemoglobin was greater in TU group (3.1 g/dL vs 2.8 g/dL, <i>P</i> = .002). The transfusion rate was 9.5% in TA compared with 11.5% in TU patients (<i>P</i> = .46) with comparable mean units transfused (2.6 vs 2.2, <i>P</i> = .30). There was no difference in wound infection (<i>P</i> = .82) and total complication rates (<i>P</i> = .27) between groups. Those patients given TXA had a lower hemoglobin drop (2.6 g/dL vs 3.3 g/dL, <i>P</i> = .04) with similar transfusion (13.3% vs 11%, <i>P</i> = .61) and complication (<i>P</i> = .95) rates.<h4>Conclusions</h4>TU TKA had a greater operative duration and postoperative drop in hemoglobin than TA TKA. However, transfusion rates were similar between groups. TXA use reduced the operative decrease in hemoglobin with no effect on complication or transfusion rates.<h4>Level of evidence</h4>Level III, retrospective cohort study.