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

• pla sty:

A r e tr

• spe 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

• pla 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

• 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 var ie ty of dosing inte r vals, as we ll as or ally or topic ally, a s de sc rib e d b y

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

• 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

• 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

ting lite r atur e re g a rding sho ulde r a rthro pla sty a nd

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

r e c e nt studie s have be e n c omple te d in this ar e a.

 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

• 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 pe r iod, at a single institution and single sur ge on, a tte mpting to

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

• plasty 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 Pac zkowskie , fr

• m Januar

y 1, 2012 thr

• ugh June 30, 2016.

 Dr. Pa c zko skie be gan using intr

ave nous tr ane xamic ac id in 2015.

 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

• spe 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

N= 220 F e ma le = 118 Ma le = 82 T XA = 80 No T XA = 140 T SA = 102 rT SA = 118 All DJD F x = 25 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 Ye s

80 279.00

No

140 243.21

Dire c t Co mpa riso n

Hb Pre o p Hb POD 0 Hb POD 1 E BL Sx time T ra nsfusio ns 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 Male

82 280.18

F e male

138 241.99

Dire c t Co mpa riso n

F e ma le N Pre o p Hb / HCT POD 0 POD 1 E BL F luids Sx T ime T ra nsfusio n No T XA 91

12.75/38.12 11.54/34.68 10.94/32.63

237 1852 93.9 7 T XA 47 12.79/ 38.87 11.45.35.11 10.68/32.86 263 1683 87.79 10 Ma le No T XA 49

14.45/43.21 13.44/40.04 12.78/37.63

270 1903 104.61 T XA 33

14.20/42.77 13.11/39.74 12.72/38.27

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

Age Group an EBL * p < 0.05

Age Gr

• up

n E BL 44 – 61

33 284.85

62 – 67 *

56 296.79

68 – 73

49 243.88

74 – 79*

52 219.23

80 – 89

30 256.23

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

all pr e vale nc e of oste oar thr itis is inc r e asing e xpo ne ntia lly a ro und

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.

Disc ussio n

 Additio na lly, b lo o d lo ss during the se surg ic a l inte rve ntio ns ma y le a d to

intra o pe ra tive a nd/ o r po sto pe ra tive a ne mia thus inc re a sing the r

isk for c ar diopulmonar y e ve nts, tr ansfusion r e ac tions, infe c tion r ate s, and ove r all inc r e ase d he alth c ar e c osts (Ga ndhi e t a l, 2013).

 T

ra ne xa mic a c id ha s b e e n use d fo r the pa st se ve ra l de c a de s to c o ntro l pe rio pe ra tive b lo o d lo ss during a nd a fte r surg e ry, ho we ve r little to no studie s ha ve b e e n pe rfo rme d in re g a rds to its use in to ta l sho ulde r a rthro pla sty until re c e ntly within the la st ye a r.

 Co nve rse ly it ha s b e e n studie d e xte nsive ly in its e ffe c tive ne ss a nd sa fe ty in

re duc ing b lo o d lo ss in to ta l kne e a rthro pla sty a nd to ta l hip a rthro pla sty a dministe re d to pic a lly a nd/ o r intra ve no usly.

Disc ussio n - L imita tio ns

 T

his study ha s se ve ra l limita tio ns.

 T

he surg e o n did not be gin using tr

ane xamic ac id in his shoulde r ar thr

• plasty patie nts until 2015, thus it is unc le a r whe the r tho se pa tie nts

who m re c e ive d the ir sho ulde r a rthro pla sty la te r in the surg e o n’ s c a re e r b e ne fite d fro m impro ve d a nd mo re e ffic ie nt te c hniq ue , c o ntrib uting to a de c re a se d o ve ra ll b lo o d lo ss a s a re sult.

 T

his study e va lua te d pre o pe ra tive a nd po sto pe ra tive he mo g lo b in a nd he ma to c rit va lue s, a s we ll a s e stima te d b lo o d lo ss during the surg e ry.

 E

stimate d blood loss is simply an e stimation tha t is a g re e d-upo n b y the

surg e o n a nd a ne sthe sia te a m a nd thus ma y b e misle a ding o r ina c c ura te .

Disc ussio n - L imita tio ns

 T

his re tro spe c tive study a lso did no t pro vide the o ppo rtunity to de te rmine

tr ansfusion c r ite r ia or pr

• toc ol, a nd thus ma ny pa tie nts re c e ive d

tra nsfusio ns witho ut a ppa re nt spe c ific g uide line s o r pro to c o l.

 One pa tie nt re q uire d a b lo o d tra nsfusio n intra o pe ra tive ly in the no n-T

XA g ro up, fa lse ly e le va te d the ir po st o pe ra tive he mo g lo b in a nd he ma to c rit va lue s whic h c a nno t b e a c c o unte d fo r in the study, the re b y fa lse ly e le va ting the no n-T XA g ro ups va lue s, a lb e it minima lly.

Co nc lusio n

 T

ra ne xa mic a c id use do e s no t de mo nstra te a sig nific a nt de c re a se in po sto pe ra tive b lo o d lo ss during to ta l sho ulde r a rthro pla sty o r re ve rse to ta l sho ulde r a rthro pla sty, no r do e s it de c re a se the o ve ra ll tra nsfusio n ra te a s de mo nstra te d in this study.

 T

he se re sults diffe r fro m re c e nt studie s tha t did de mo nstra te a sig nific a nt re duc tio n in b lo o d lo ss a nd tra nsfusio n ra te s.

 T

he re wa s a sub je c tive sig nific a nt diffe re nc e no te d in the fra c ture g ro up in re g a rds to inc re a se d tra nsfusio n ra te s, ho we ve r no diffe re nc e with T XA use (in fa c t hig he r tra nsfusio n ra te ).

 T

he re wa s a lso a sig nific a nt diffe re nc e b e twe e n ma le a nd fe ma le pre o pe ra tive he mo g lo b in a nd he ma to c rit va lue s, ho we ve r no sta tistic a lly sig nific a nt pe rc e ntile diffe re nc e in the o ve ra ll c ha ng e .

 F

e ma le s we re a t a muc h hig he r sta tistic a lly sig nific a nt ra te o f tra nsfusio n (17/ 18 to ta l tra nsfusio ns) a s c o mpa re d to ma le s in b o th the T XA a nd no n-T XA g ro ups.

Co nc lusio n

 I

n a dditio n, no sig nific a nt sta tistic a l diffe re nc e e xiste d with T XA use in rT SA in fra c ture ve rsus DJD, ho we ve r the o ve ra ll pre o pe ra tive he mo g lo b in wa s lo we r a nd the E BL a nd tra nsfusio n ra te wa s hig he r in the fra c ture g ro up inde pe nde nt o f T XA use whe n c o mpa re d to the DJD g ro up.

 14/ 18 tra nsfusio ns in rT

SA g ro up

 T

he rT SA fra c ture g ro up, inde pe nde nt o f T XA use , re c e ive d 12 tra nsfusio ns

• ve ra ll o ut o f 25 to ta l pa tie nts (48%), thus de mo nstra ting a ne e d fo r

tra nsfusio n pro to c o l a nd c a re ful mo nito ring o f the se pa tie nts po sto pe ra tive ly.

Co nc lusio n

 F

urthe r re se a rc h is ne e de d to a sse ss a g ro up o f surg e o ns, ra the r tha n a sing le surg e o n, in re ve rse to ta l sho ulde r a rthro pla sty a nd sho ulde r he mia rthro pla sty, a s this ma y indic a te a hig he r o r le sse r inc ide nc e o f b lo o d lo ss with a la rg e r sa mple size a nd diffe ring surg ic a l te c hniq ue .

 T

• pic a l T

XA a dministra tio n ma y b e re se a rc he d furthe r a s we ll, ho we ve r in the c urre nt lite ra ture no o b vio us b e ne fit o r sta tistic a l a dva nta g e e xists fo r its use ve rsus intra ve no us a dministra tio n.

 Stric t tra nsfusio n c rite ria must b e de ve lo pe d a nd a dhe re d to in

• rde r to de c re a se o ve ra ll tra nsfusio n ra te s fo r a ll surg ic a l pa tie nts,

spe c ific a lly sho ulde r a rthro pla sty pa tie nts in this study.

Re fe re nc e s

 Ab ildg a a rd, J.T

., Mc L e mo re , R., a nd Ha ttrup, S.J. (2016). T ra ne xa mic a c id de c re a se s b lo o d lo ss in 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. Jo urnal o f Sho ulde r and E lb o w Surg e ry, 25, 1643- 1648.

 Alshryda , S., Suke ik, M., Sa rda , P., Ble nkinso pp, J., Ha dda d, F

.S., a nd Ma so n, J.M. (2014). A syste ma tic re vie w a nd me ta -a na lysis o f the to pic a l a dministra tio n o f tra ne xa mic a c id in to ta l hip a nd kne e re pla c e me nt. T he Bo ne & Jo int Jo urnal, 96-B(8), 1005-1015.

 Che n, J.Y., Chia , S., L

• , N.N., & Ye o , S.J. (2015). I

ntra -a rtic ula r ve rsus intra ve no us tra ne xa mic a c id in prima ry to ta l kne e re pla c e me nt. Annals o f T ranslatio nal Me dic ine , 3(3), 33.

 Cla ve , A., F

a zille a u, F ., Dumse r, D., a nd L a c ro ix, J. (2012). E ffic a c y o f tra ne xa mic a c id o n b lo o d lo ss a fte r prima ry c e me ntle ss to ta l hip re pla c e me nt with riva ro xa b a n thro mb o pro phyla xis: A c a se -c o ntro l study in 70 pa tie nts. Ortho pae dic s & T raumato lo g y: Surg e ry & Re se arc h, 98, 484- 490.

 Da ng , P., a nd Sc hwa rzko pf, R. (2013). T

ra ne xa mic Ac id a nd T

• ta l K

ne e Arthro pla sty. Annals o f Ortho pe dic s & Rhe umato lo g y, 1(1), 1001.

 F

rie dma n, R.J., Go rdo n, E ., Butle r, R.B., Mo c k, L ., a nd Duma s, B. (2016). T ra ne xa mic a c id de c re a se s b lo o d lo ss a fte r to ta l sho ulde r a rthro pla sty. Jo urnal o f Sho ulde r and E lb o w Surg e ry, 25, 614-618.

Re fe re nc e s

 Ga ndhi, R., E

va ns, H., Ma ho me d, S.R., a nd Ma ho me d, N.N. (2013). T ra ne xa mic a c id a nd the re duc tio n o f b lo o d lo ss in to ta l kne e a nd hip a rthro pla sty: a me ta -a na lysis. BMC Re se arc h No te s, 6(184), 1-14.

 Hippa la , S., Strid, L

., We nne rstra nd , M., Arve la , V., Ma ntyla , S., & Yline n, J. (1995). T ra ne xe mic Ac id (Cyklo a pro n) re duc e s pe rio pe ra tive b lo o d lo ss a sso c ia te d with to ta l kne e a rthro pla sty. British Jo urnal o f Ane sthe sia, 74, 534-537.

 Hippa la , S.T

., Strid, L .J., We nne rstra nd , M.I ., Arve la , J.V.V., Nie me la , H.M., Ma ntyla , S.K ., K uisma , R.P., & Yline n, J.E . (1997). T ra ne xe mic Ac id Ra dic a lly De c re a se s Blo o d L

• ss a nd T

ra nsfusio ns Asso c ia te d with T

• ta l K

ne e Arthro pla sty. Ane sthe sia and Analg e sia Jo urnal, 84, 839-844.

 I

risso n, E ., He mo n, Y., Pa uly, V., Pa rra tte , S., Arg e nso n, J.N., a nd K e rb a ul, F . (2012). T ra ne xa mic a c id re duc e s b lo o d lo ss a nd fina nc ia l c o st in prima ry to ta l hip a nd kne e re pla c e me nt surg e ry. Ortho pae dic s & T raumato lo g y: Surg e ry & Re se arc h, 98, 477-483.

 I

shida , K ., T sumura , N. K ita g a wa , A., Ha ma mura , S., F ukuda , K ., Do g a ki, Y., K ub o , S., Ma tsumo to , T ., Ma tsushita , T ., Chin, T ., I g uc hi, T ., K uro sa ka , M., a nd K uro da , R. (2011). I ntra -a rtic ula r inje c tio n o f tra ne xa mic a c id re duc e s no t

• nly b lo o d lo ss b ut a lso kne e jo int swe lling a fte r to ta l kne e a rthro pla sty.

I nte rnatio nal Ortho pae dic s, 35, 1639-1645.

Re fe re nc e s

 Ma nia r, R.N., K

uma r, G., a nd Na ya k, R.M. (2012). Mo st E ffe c tive Re g ime n o f T ra ne xa mic Ac id in K ne e Arthro pla sty. Clinic al Ortho pae dic s and Re late d Re se arc h, 470, 2605-2612.

 Na po lita no , L

.M., Co he n, M.J., Co tto n, B.A., Sc hre ib e r, M.A., a nd Mo o re , E .E . (2013). T ra ne xa mic a c id in tra uma : Ho w sho uld we use it? Jo urnal o f T rauma and Ac ute Care Surg e ry, 74(6), 1575-1586.

 Orte g a -Andre u, M., Pe re z-Chrza no wska , H., F

ig ue re do , R., a nd Go me z-Ba rre na , E . (2011). Blo o d L

• ss Co ntro l with T

wo Do se s o f T ra ne xa mic Ac id in a Multimo da l Pro to c o l fo r T

• ta l K

ne e Arthro pla sty. T he Ope n Ortho pae dic s Jo urnal, 5, 44-48.

 Pa uze nb e rg e r, L

., He ub e rg e r, P.R., L a ky, B., K rie g le de r, a nd Ande rl, W. (2016). T ra ne xa mic a c id in to ta l sho ulde r a rthro pla sty: A ra ndo mise d, c o ntro lle d tria l. T he Jo urnal o f Bo ne and Jo int Surg e ry; Ortho pae dic Pro c e e ding s, 98-B (supple me ntal 9), 125.

 Po e ra n, J., Ra sul, R., Suzuki, S., Da nning e r, T

., Ma zumda r, M., Oppe re r, M., Bo e ttne r, a nd F ., Me mtso udis, S.G. (2014). T ra ne xa mic a c id use a nd po sto pe ra tive o utc o me s in pa tie nts unde rg o ing to ta l hip o r kne e a rthro pla sty in the Unite d Sta te s: re tro spe c tive a na lysis o f e ffe c tive ne ss a nd sa fe ty. British Me dic al Jo urnal, 349(g 4829), 1-10.

 Ro b e rts, I., Sha kur, H., Co a ts, T

., Hunt, B., Ba lo g un, E ., Ba rne tso n, L ., Co o k, L ., K a wa ha ra , T ., Pe re l, P., Prie to -Me rino , D., Ra mo s, M., Ca irns, J., a nd Gue rrie ro , C. (2013). T he CRASH-2 tria l; a ra ndo mise d c o ntro lle d tria l a nd e c o no mic e va lua tio n o f the e ffe c ts o f tra ne xa mic a c id o n de a th, va sc ula r o c c lusive e ve nts a nd tra nsfusio n re q uire me nts in b le e ding tra uma pa tie nts. He alth T e c hno lo g y Asse ssme nt, 17(10), i- xii, 1-79.

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