LA Orthopedic Institute Ed McPherson, M.D. Las Vegas, USA 07 December 2017
Orthopaedic Summit 2017 Knee Arthroplasty Session Blood Management: TEXA IV, Topical or Oral Is There a Difference? What is Best? Las Vegas, USA 07 December 2017
AAOS 2017 Disclosures • Biocomposites Inc. • Concept Design Development LLC • Joint Implant Surg Research Found. • Miller Orthopaedic Review • Zimmer Biomet Inc.
Tranexamic Acid in TKA Balance • Benefit vs. Harm • Cost vs. Savings • Protocol complexity vs. simplicity • Patient tolerance to treatment Best “Safe Bang” for the Buck?
TKA Outcomes We Are All Being Monitored • Closely! • Next year for cms, primary tka is an outpatient procedure • Goal: good outcomes with low los with a tka protocol that is financially viable Medical Informatics is Here
TKA Outcomes Minimizing Blood Loss • Better patient vigor • Faster patient mobilization more noticeable in debilitated patients • With a reduced los & transfusion: less chance for nosocomial complications
Clotting Cascade TKA Surgery • Surgery cuts tissues and vessels clotting cascade → clot that seals open holes • Fibrinolysis breaks down clot why? → control size of clot feedback loop & starts healing process
www.quigen.com Remodeling/Healing Phase
Fibrinolysis TKA/THA Surgery • Fibrinolysis peaks 6 hours after procedure and settles down at 18 hours • Reducing fibrinolysis at knee surgery site will stabilize clot longer resulting in decreased perioperative blood loss DOI:10.1016/j.thromres.2012.11.006
Tranexamic Acid (TEXA) Basics • Discovered 1962 - Utako Okamoto • Antifibrinolytic - ½ life ≈ 3 hours reversibly binds to 4-5 lysine receptors on plasminogen & plasmin keeps plasmin from binding to & degrading fibrin clot excretion is renal - 95% as orig molecule
TEXA Works Here www.intechopin.com
Due to structural similarities to lysine, tranexamic acid competitively inhibits binding of fibrin to plasminogen via interaction at an active lysine-binding site Fibrinolysis is prevented, with concomitant stabilization of the fibrin clot Dunn CJ, Goa KL Drugs 57:1005 99’
Tranexamic Acid (TEXA) Reduces Perioperative Inflammation • Plasmin & D-dimer fragments stimulate inflammatory response pain, swelling, tissue permeability IL-6, IL-8, TNF- α • Reduction of fibrinolysis → reduction in knee inflammation PMCID : PMC2246206
Tranexamic Acid in TKA All Current META Analysis (5yrs) • All routes of treatment effective in decreasing measured blood loss and transfusion rates compared to controls oral, iv, topical, intra-articular • Rates of thromboembolic events not significantly different to controls
Tranexamic Acid in TKA Why is DVT/PE Rate Not Affected? • Biopsy study of veins after 3 weeks of oral TEXA (n=16) txa did not suppress the fibrinolytic activity in vein vessel walls • Short duration of treatment in TKA compared to other applications PMID 742821
IV TEXA in TKA Academic Argument For • Five dose regimen covering the entire 18 hours of the fibrinolysis event lower hidden blood loss lowest fibrinolysis (fdp & d-dimer) reduced inflammation (IL-6) reduced los & increased rom Lei Y, et al. Intl Ortho(SCOIT) 41:2053 17’
Oral TEXA in TKA Effective But • Bioavailability is approximately 30% • Problem is with patient tolerance & logistics nausea & vomiting perioperatively competition with all other “pills” for pain regimen must start 2 hours before surgery
Study Exclusions Deep Dive of RCT’s & META Analysis • DVT/PE • CADz/PADz • CVA/TIA • Prothrombotic disorder • Cardiac stenting • Kidney dz • MI w/in 6 months • ERT • A-fib
Tranexamic Acid in TKA Arterial Clotting • Damaged vessels from atherosclerotic disease have abnormal rheology and are prone to endothelial damage • Older populations have a higher prevalence of endothelial disease • TEXA use is off label & was not evaluated in elderly population
Study Exclusions Contraindications to IV TEXA • Known hypersensitivity • Seizure disorder lysine competes with glycine receptors in the brain → “disinhibition” PMID 24385043
IV Tranexamic Acid in TKA Exclusion Rate at Our Center • 12% 2014 n=39 54% of my • 12% 2015 n=39 patients are ASA • 14% 2016 n=49 3 or 4 • 17% 2017 n=46 IV TEXA: Liability is a Shared Risk between Orthopaedics, Anesthesia & Medicine
Topical TEXA in TKA Practical (RLO) Argument For • Targeted therapy → site of injury • < 30% systemic levels compared to iv dosing regimen • Only one dose → lowest risk regimen PMID 21048170
Tranexamic Acid in TKA Summary • Blood loss in TKA is not life threatening • Thus regimens to reduce blood loss should be commensurate Best “Safe Bang” for the Buck
Tranexamic Acid in TKA Balance • 2 dose iv regimen 10mg/kg (1gm) 15 min before tourniquet inflation 15 min before tourniq deflat or recovery • No contraindications META DOI 10.1007/s00167-016-4235-6 Best “Safe Bang” for the Buck
Tranexamic Acid in TKA Balance • One dose topical regimen 3gm/100cc 1/3 rd after bone cuts, rest at closure 5 min minimum exposure time • For contraindications or all patients META DOI 10.1007/s00264-016-3296-y Best “Safe Bang” for the Buck
Tranexamic Acid (TEXA) Summary • Safe & cost effective agent in reducing perioperative blood loss in tja don ’ t let pharmacy mark it up!! • I use it for all cases - primary & revision tka, tha, & tsa PMID 15562053
TKA Outcomes You Are The Team Captain • Surgeon leadership requires aptitude in many areas including patient advocacy technical ability team management financial stewardship interdisciplinary collegiality
Orthopaedic Summit 2017 Knee Arthroplasty Session Blood Management: TXA, IV, Topical or Oral Thank You Las Vegas, USA 07 December 2017
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