Sunday, February 12, 2017

Bleeding from reverse total shoulder - effect of tranexamic acid

Intravenous tranexamic acid reduces total blood loss in reverse total shoulder arthroplasty: a prospective, double-blinded, randomized, controlled trial

These authors conducted a prospective, double-blinded, single-surgeon trial, of 102 patients undergoing primary reverse total shoulder arthroplasty who were randomized to receive intravenous tranexamic acid (TXA) (n = 53) or placebo (n = 49).

Total blood loss was less for the TXA group (1122.4 ± 411.6 mL) than the placebo group
(1472.6 ± 475.4 mL, P < .001). 
Total drain output was less for the TXA group (221.4 ± 126.2 mL) than the placebo group (371.9 ± 166.3 mL , P < .001). 
Total Hb loss was less in the TXA group (154.57 ± 60.29 g) compared with the placebo group (200.1 ± 65.5 g, P = .001). 
Seven patients (14.3%) and 12 units were transfused in the placebo group compared with 3 patients (5.7%) and 3 units in the TXA group.

Comment: This is a well-done randomized controlled trial showing the effectiveness of TXA. In our view, the major value of TXA is not reducing the need for transfusion, but rather reduction in the postoperative bleeding into the shoulder that can increase infection risk and pain. 

In our practice we do not use drains and almost never need to transfuse a patient after a primary, reverse or revision shoulder arthroplasty. We use TXA primarily to minimize bleeding and swelling the wound area. The principal contraindications for its use are (1) a prior thromboembolic event or (2) increased risk of a thromboembolic event (cancer, atrial fibrillation, hormone replacement therapy).