Saturday, January 9, 2016

Shoulder joint replacement - making it safer with tranexamic acid

Tranexamic acid decreases blood loss after total shoulder arthroplasty.

These authors compared the preoperative blood loss in 106 patients undergoing primary anatomic and reverse TSA who received 20 mg/kg of tranexamic acid (TXA) intravenously with the preoperative blood loss for the previous consecutive 88 patients without TXA. 

They observed statistically significant differences in both hemoglobin loss (TXA group Δ = 2.13 vs. non-TXA group Δ = 2.63; P = .01) and hematocrit loss (TXA group Δ = 6.4 vs. non-TXA group Δ = 8.14; P < .01) seen in the TXA group compared with the non-TXA group. Two patients in the TXA group received a blood transfusion, whereas 6 patients in the non-TXA group did.

Patients receiving TXA spent less time in the recovery room (mean, TXA group 69 minutes vs. non-TXA group 87 minutes; P < .02) and had shorter total length of hospitalization (mean, TXA group 1.18 days vs. non-TXA group 1.4 days; P = .01). 

Comment: As the authors point out, the one weakness of this study is the use of historical controls, however, since this is a mature practice and the controls immediately preceded the treatment group, the risk of confounding seems small.

The benefit of reducing bleeding after shoulder arthroplasty is not so much the reduction in the need for transfusion (which is very uncommon in our practice and that of the authors), but rather in the reduction of bleeding into the tissues around the shoulder, which can increase pain and compromise early range of motion exercises.

It is interesting that shoulder arthroplasty is performed in a beach chair position with the patient anesthetized - both of which reduce the local blood pressure in the shoulder and, therefore, the tendency for bleeding around the shoulder. However, when the patient is placed supine in the recovery room and the anesthetic wears off, the local shoulder blood pressure and the tendency to bleed increase. The point is that the absence of bleeding on wound closure in the OR does not preclude bleeding in the recovery room.

We use tranexamic acid in most of our patients, except for those with a history or increased risk of thromboembolic problems or cardiac ischemia. There are other contraindications listed on the product label that need to be considered as well.