Saturday, January 9, 2021

Tranexamic acid in shoulder arthroplasty - effectiveness and safety

 A Single Dose of Tranexamic Acid Reduces Blood Loss After Reverse and Anatomic Shoulder Arthroplasty: A Randomized Control Trial

These authors conducted a double-blinded randomized controlled trial comparing intravenous TXA to placebo in 60 patients undergoing primary anatomic and reverse shoulder arthroplasty. 29 patients received a placebo whilst 31 received a single dose of 2g of intravenous TXA.

Patients who received TXA had lower drain tube outputs at all time points. They also had higher postoperative Hb (12.3 vs 11.4; P=0.009), lower change in Hb (1.7 vs 2.3; P=0.011), lower total Hb loss (0.078g vs 0.103g; P=0.042) and blood volume loss (0.55L vs 0.74L; P=0.021), higher postoperative hematocrit (36.7 vs 34.6; P=0.020) and lower hematocrit change (5.4 vs 7.6; P=0.022). 

The authors found no differences detected in occurrence of complications, need for transfusion, pain scores or length of hospital stay. 

Comment: This relatively small study does not address the safety of TXA in patients at higher risk for thromboembolic events. The study below does address this point:

Administration of tranexamic acid during total shoulder arthroplasty is not associated with increased risk of complications in patients with a history of thrombotic events 

These authors point out that tranexamic acid (TXA) has been shown to reduce blood loss and transfusion risk in shoulder arthroplasty, but that concerns exist regarding its safety in patients with a history of thrombotic events. 

They used national claims data to study the safety of TXA administration in shoulder arthroplasty patients with a history of thrombotic events such as myocardial infarction, deep venous thrombosis, pulmonary embolism, transient ischemic attack, or ischemic stroke. 

Overall, TXA was used in 13.7% (n 9735) of patients, whereas 10.5% (n 7475) of patients had a history of a thrombotic event.

TXA use (compared with no TXA use) in patients without a history of thrombotic events was associated with decreased odds of blood transfusions (OR, 0.48), whereas no increased odds for complications were observed (OR, 0.83). 

Similar results were observed in patients with a history of thrombotic events.

Moreover, in this subgroup, TXA use was associated with a 8.9% reduction in hospitalization cost.

As shown below, patients with a history of thromboembolic events had a higher risk of a thromboembolic event after shoulder arthroplasty, but TXA use did not increase this use.

 Comment: These data appear to support the use of TXA in patients at increased risk for thromboembolic events (TEEs). Note that according to these statistics 4.6 patients out of 100 with a prior history of TEEs would have a new TEE, so surgeons should be prepared for the possibility that a patient receiving TXA could have a thromboembolic event. The question of causation could arise. In this light, consideration might be given to the use of topical TXA (rather than IV TXA) in patients at increased risk for thromboembolic events.


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