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LA Orthopedic Institute Ed McPherson, M.D. Las Vegas, USA 07 - - PowerPoint PPT Presentation
LA Orthopedic Institute Ed McPherson, M.D. Las Vegas, USA 07 - - PowerPoint PPT Presentation
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
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AAOS 2017
Disclosures
- Biocomposites Inc.
- Concept Design Development LLC
- Joint Implant Surg Research Found.
- Miller Orthopaedic Review
- Zimmer Biomet Inc.
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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?
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TKA Outcomes
We Are All Being Monitored
- Closely!
- Next year for cms, primary tka is an
- utpatient procedure
- Goal: good outcomes with low los with
a tka protocol that is financially viable
Medical Informatics is Here
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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
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Clotting Cascade
TKA Surgery
- Surgery cuts tissues and vessels
clotting cascade → clot that seals
- pen holes
- Fibrinolysis breaks down clot
why? → control size of clot feedback loop & starts healing process
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www.quigen.com Remodeling/Healing Phase
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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
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Tranexamic Acid (TEXA)
Basics
- Discovered 1962 - Utako Okamoto
- Antifibrinolytic - ½ life ≈ 3 hours
reversibly binds to 4-5 lysine receptors
- n plasminogen & plasmin
keeps plasmin from binding to &
degrading fibrin clot
excretion is renal - 95% as orig molecule
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TEXA Works Here
www.intechopin.com
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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’
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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
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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
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Tranexamic Acid in TKA
Why is DVT/PE Rate Not Affected?
- Biopsy study of veins after 3 weeks of
- ral 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
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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’
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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
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Study Exclusions
Deep Dive of RCT’s & META Analysis
- DVT/PE
- CVA/TIA
- Cardiac stenting
- MI w/in 6 months
- A-fib
- CADz/PADz
- Prothrombotic
disorder
- Kidney dz
- ERT
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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
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Study Exclusions
Contraindications to IV TEXA
- Known hypersensitivity
- Seizure disorder
lysine competes with glycine receptors
in the brain → “disinhibition”
PMID 24385043
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IV Tranexamic Acid in TKA
Exclusion Rate at Our Center
- 12%
2014 n=39
- 12%
2015 n=39
- 14%
2016 n=49
- 17%
2017 n=46
IV TEXA: Liability is a Shared Risk between Orthopaedics, Anesthesia & Medicine
54% of my patients are ASA 3 or 4
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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
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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
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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
Best “Safe Bang” for the Buck
META DOI 10.1007/s00167-016-4235-6
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Tranexamic Acid in TKA
Balance
- One dose topical regimen 3gm/100cc
1/3rd after bone cuts, rest at closure 5 min minimum exposure time
- For contraindications or all patients
Best “Safe Bang” for the Buck
META DOI 10.1007/s00264-016-3296-y
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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
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TKA Outcomes
- Surgeon leadership requires aptitude
in many areas including
patient advocacy technical ability team management financial stewardship interdisciplinary collegiality
You Are The Team Captain
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