T r a ne xa mic Ac id Use in Shoulde r Ar thr opla sty: A r - PowerPoint PPT Presentation

T r a ne xa mic Ac id Use in Shoulde r Ar thr opla sty: A r e tr ospe c tive a na lysis of tr a ne xa mic a c id use in tota l a nd r e ve r se tota l shoulde r a r thr opla sty to r e duc e pe r iope r a tive blood loss a nd tr a nsfusion r a te s Matthe w S. I rwin, D.O., M.S., PGY-5 Ortho pae dic Surg e ry L E COM Vinc e nt Pac zko skie , M.D. Ste ve n Hab usta, D.O. Mic hae l Bo g ard, OMS-I I I L E COM

Ba sic Sc ie nc e – T ra ne xa mic Ac id  T ra ne xa mic a c id (T XA), tra ns-4-(a mino me thyl)c yc lo he xa ne c a rb o xylic a c id, is a white c rysta lline po wde r tha t a c ts a s a n a ntifib rino lytic a g e nt, typic a lly disso lve d in a ste rile so lutio n, a nd ma y b e a dministe re d to pic a lly o r intra ve no usly (F DA, 2011).  T ra ne xa mic a c id is a c o mpe titive inhib ito r o f pla smino g e n a c tiva tio n, a nd a t muc h hig he r le ve ls, a no nc o mpe titive inhib ito r o f pla smin.  I t func tio ns b y bloc king the lysine binding site s on plasminoge n , the re b y slo wing the c o nve rsio n o f pla smino g e n to pla smin.  While its a c tio ns a re q uite simila r to a mino c a pro ic a c id, in vitro studie s de mo nstra te it is ne a rly te n time s mo re po te nt.

Ba sic Sc ie nc e  An a ntifib rino lytic c o nc e ntra tio n o f tra ne xa mic a c id re ma ins in a va rie ty o f tissue s fo r a ppro xima te ly 17 ho urs a nd in the se rum fo r a ppro xima te ly 8 ho urs (F DA, 2011).  As no te d pre vio usly tra ne xa mic a c id may be de live r e d intr ave nously in a topic ally , a s de sc rib e d b y var ie ty of dosing inte r vals, as we ll as or ally or Che n e t a l (2015).  Mo st e ffe c tive whe n g ive n b e fo re hype rfib rino lysis c a use d b y tissue injury during surg e ry

T XA re se a rc h in T o ta l K ne e Arthro pla sty  T XA, whe n g ive n intra ve no usly, ha s a wide distrib utio n thro ug h b o th the intra c e llula r a nd e xtra c e llula r c o mpa rtme nt.  I t diffuse s ra pidly into this syno via l fluid until the the c o nc e ntra tio n e q ua ls tha t the se rum.  Pre vio us me ta -a na lyse s ha ve de mo nstra te d intra ve no us T XA e ffe c tive ly re duc e s the pe rio pe ra tive b lo o d lo ss a nd inc ide nc e a b lo o d tra nsfusio n a fte r to ta l kne e re pla c e me nt, witho ut inc re a sing the risk o f thro mb o e mb o lic e ve nts (Che n e t a l, 2015).  T o pic a l a dministra tio n o f tra ne xa mic a c id fo llo wing to ta l kne e a rthro pla sty with c e me nt dire c tly into the surg ic a l wo und re duc e d po sto pe ra tive b le e ding b y 20-25% with no inc re a se in c o mplic a tio n ra te (Wo ng e t a l, 2010).

T XA in sho ulde r a rthro pla sty  Nume ro us pre vio us studie s ha ve a na lyze d the use o f tra ne xa mic a c id to re duc e b lo o d lo ss during to ta l kne e a rthro pla sty a nd to ta l hip a rthro pla sty, thus de c re a sing the ne e d fo r b lo o d tra nsfusio n.  T he re wa s a lac k of suppor e re g a rding sho ulde r a rthro pla sty a nd ting lite r atur the use o f tra ne xa mic a c id to re duc e b lo o d lo ss a t the b e g inning o f this pro je c t, howe ve r e a . r e c e nt studie s have be e n c omple te d in this ar  F rie dma n e t a l (2016) re c e ntly c o mple te d finding s tha t de mo nstra te sta tistic a lly sig nific a nt de c re a se s o f 21% in b lo o d lo ss in pa tie nts unde rg o ing to ta l sho ulde r a rthro pla sty a nd/ o r re ve rse to ta l sho ulde r a rthro pla sty.  Ab ildg a a rd e t a l (2016) a lso re c e ntly pub lishe d finding s tha t c o nc lude d simila r sta tistic a lly sig nific a nt b lo o d lo ss in b o th to ta l sho ulde r a rthro pla sty a nd re ve rse to ta l sho ulde r a rthro pla sty.

T o ta l Jo int Arthro pla sty in the Unite d Sta te s  T he pre va le nc e o f a rthro pla sty in Unite d Sta te s is ste a dily inc re a sing with o ur a g ing po pula tio n.  Blo o d lo ss during the se pro c e dure s re ma ins a c o nside ra b le risk a nd me tho ds to re duc e b lo o d lo ss during surg e ry a re a n impo rta nt, a nd c o ntro ve rsia l, to pic o f disc ussio n.  T ra nsfusio n risk still pre se nt de spite impro ve d te c hno lo g y a nd filte ring pro c e sse s, inc luding inc re a se d risk fo r o pe ra tive site infe c tio n.  T his study will a na lyze the da ta fro m patie nts ove r a five - ye ar ge on , a tte mpting to pe r iod, at a single institution and single sur de te rmine if intra ve no us T XA use during to ta l sho ulde r a nd re ve rse to ta l sho ulde r a rthro pla sty re duc e s pe rio pe ra tive b lo o d lo ss a nd tra nsfusio n ra te s.

Me tho ds  T his study wa s a ppro ve d thro ug h the I nstitutio na l Re vie w Bo a rd a t Me a dville Me dic a l Ce nte r, Me a dville , Pe nnsylva nia a nd L a ke E rie Co lle g e o f Oste o pa thic Me dic ine , E rie , Pe nnsylva nia .  T his study is a re tro spe c tive c o ho rt a na lysis o f two hundr e d twe nty patie nts unde r going shoulde r ar thr oplasty at one 210- be d institution, Me adville Me dic al Ce nte r , pe r for me d by one sur ge on, Dr . Vinc e nt ough June 30, 2016 . Pac zkowskie , fr om Januar y 1, 2012 thr  Dr. Pa c zko skie be gan using intr ane xamic ac id in 2015 . ave nous tr  T his study me a sure d the a sso c ia tio n b e twe e n tra ne xa mic a c id use a nd b lo o d lo ss in the pe rio pe ra tive pe rio d.  T he da ta o f the two hundre d twe nty pa tie nts’ surg ic a l file s fro m Me a dville Me dic a l Ce nte r we re gathe r e d r e tr ospe c tive ly without dir e c t or indir e c t ide ntifie r s.

Me tho ds  Da ta a na lyze d inc lude d:  Se x  Ag e  Pre o pe ra tive he mo g lo b in a nd he ma to c rit va lue s  Po sto pe ra tive he mo g lo b in a nd he ma to c rit va lue s  Ne e d fo r tra nsfusio n  L e ng th o f surg e ry  E stima te d b lo o d lo ss intra o pe ra tive ly  I ntra ve no us fluids a dministe re d intra o pe ra tive ly  T ra ne xa mic a c id use  F ra c ture ve rsus DJD  T he se va lue s we re the n sta tistic a lly a na lyze d via Mic ro so ft E xc e l 2015 a nd Sta tPlus so ftwa re .

Summa ry o f Da ta Ma le = 82 N= 220 F e ma le = 118 T XA = 80 No T XA = 140 T SA = 102 rT SA = 118 x = 25 F All DJD DJD = 93

TXA Use and EBL A one-way analysis of variance was conducted to compare the effect of gender on preoperative and postoperative hemoglobin and hematocrit values. An analysis of variance showed gender had no significant effect on these levels. TXA use was also analyzed in comparison with hemoglobin and hematocrit values, where no significance was found either. T XA Use n E BL 80 279.00 Ye s 140 243.21 No

Dire c t Co mpa riso n Hb Hb Hb POD 1 E BL Sx time T ra nsfusio ns Pre o p POD 0 T XA 13.37 12.13 11.51 279 92.79 11 No T XA 13.35 12.2 11.6 249 97.65 7

Gender and Estimated Blood Loss Averages p = 0.056 n E BL 82 280.18 Male 138 241.99 F e male

Dire c t Co mpa riso n Pre o p F e ma le N Hb / HCT POD 0 POD 1 E BL F luids Sx T ime T ra nsfusio n 12.75/38.12 11.54/34.68 10.94/32.63 No T XA 91 237 1852 93.9 7 11.45.35.11 10.68/32.86 T XA 47 12.79/ 38.87 263 1683 87.79 10 Ma le 14.45/43.21 13.44/40.04 12.78/37.63 No T XA 49 270 1903 104.61 0 14.20/42.77 13.11/39.74 12.72/38.27 T XA 33 302 1889 99.91 1

Dire c t Co mpa riso n rT SA T XA Numb e r Ag e Hb Pre o p Hb POD 0 Hb POD 1 E BL Sx time T ra nsfusio ns F x 15 73.33 10.82 9.64 9.48 303 109 8 No F x 35 75.11 13.81 12.62 11.97 251 83 2 rT SA No T XA Numb e r Ag e Hb Pre o p Hb POD 0 Hb POD 1 E BL Sx time T ra nsfusio ns F x 10 72.5 11.51 9.63 10.23 320 94 4 No F x 58 71.64 13.21 12.01 11.31 233 98.34 0

Age Group an EBL * p < 0.05 Age n E BL Gr oup 33 284.85 44 – 61 56 296.79 62 – 67 * 49 243.88 68 – 73 52 219.23 74 – 79* 30 256.23 80 – 89

Disc ussio n  Ac c o rding to the Unite d Sta te s Ce nsus Bure a u a s o f April 30, 2016, the c urre nt po pula tio n within the Unite d Sta te s e xc e e ds 323 millio n pe o ple .  T he po pula tio n in the Unite d Sta te s c o ntinue s to a g e a t a la rming ra te s with ne a rly 50 millio n pe o ple c urre ntly a g e 65 o r o lde r, a nd c o ntinuing to inc re a se to ne a rly 90 millio n b y 2050, a c c o rding to c e nsus re po rts.  T his c urre ntly a c c o unts fo r 15% o f o ur na tio n’ s po pula tio n a nd b y 2050 will e nc o mpa ss o ve r 20%.  T he ove r e asing e xpo ne ntia lly a ro und all pr e vale nc e of oste oar thr itis is inc r the wo rld a nd the ne e d fo r tre a tme nt, suc h a s to ta l kne e , hip a nd sho ulde r a rthro pla sty c o ntinue s to b e the de finitive e ffe c tive tre a tme nt.  T he pre va le nc e o f the se tre a tme nts a re the re fo re inc re a sing a s we ll a nd a re a sso c ia te d with sig nific a nt b lo o d lo ss tha t ma y re q uire b lo o d tra nsfusio n.