SLR - June 2020 - Sarah A. Gostich

Tranexamic Acid in the Perioperative Period Yes, No, Maybe

Reference: Justin E. Richards, MDa, Ron E. Samet, MDa, A. Kennedy Koerner, MDb, homas E. Grissom, MD, MSIS, FCCMa, Tranexamic Acid in the Perioperative Period Yes, No, Maybe. Advances In Anesthesia. 2019 December; 37, 87-110

Scientific Literature Review

Reviewed By: Sarah A. Gostich, DPM
Residency Program: Bethesda Hospital East/West – Boynton Beach, FL

Podiatric Relevance: Tranexamic Acid is a fibrinolytic inhibitor and helps prevent blood clots from breaking down. It is widely used in orthopedic surgery to decrease the need for blood transfusions and reduce intraoperative bleeding. Though not often, foot & ankle surgeons do come across complications from intraoperative bleeding. Chronic anemia further complicates intraoperative bleeding, which is vastly seen in our patient population. This article points to research showing  an increase in surgical site infections with blood transfusions and intraoperative bleeding. This is certainly relevant to podiatric surgery, especially in our longer reconstructive procedures, or those situations where a tourniquet is contraindicated.

Methods: This article was intended to review the most recent clinical experiences and recommendations, along with the history and pharmacology of TXA. With regard to TXA use in orthopedic surgery, this review article set out to answer three primary questions. (One) Does TXA administration improve outcomes, and if so, which outcomes?; (Two) Via what route (ie, IV or topical) is TXA most beneficial?; and (Three) Is there an optimal dose of TXA in orthopedic surgery

Results: The first question regarding efficacy of TXA in orthopedic surgery has been addressed in multiple prospective, randomized studies and subsequent metanalyses. TXA has been shown to decrease the incidence and rate of red blood cell transfusion in primary hip arthroplasty, knee arthroplasty, and acute fractures without a significant increase in thrombo- embolic complications. To answer the second question, the article analyzed comparative studies that have evaluated topical TXA versus IV TXA demonstrating noninferiority with regards to blood transfusion requirements, whereas combined topical and IV TXA compared with IV TXA was associated with improved outcomes. Lastly, there is little evidence to guide optimal dosing of TXA in total joint arthroplasty.

Conclusions: This review article references an overwhelming amount of research that advocates the use of TXA for any surgery with an EBL of 500 millileters. The use of TXA has been widely adopted by orthopedic and spine surgery. Additionally, this review points out the research suggesting a decrease in wound infection with the use of TMX by decreasing the need for red blood cell transfusion and TXA’s ability to decrease inflammation. Current areas of controversy seem to be centered around the role of TXA in trauma and postpartum hemorrhage despite massive trails showing benefit. Studies show that EBL is grossly underestimated by surgeons. Foot & Ankle surgeons may be surprised by the actual blood loss of their surgical procedures, considering 500 millileters of blood loss is approximately five soaked laps. Over the last 20 years, the clinical use of TXA has expanded significantly as evidenced by the amount of research and number of publications focusing on its use in a broad range of clinical applications. The use of TXA should be considered in foot & ankle surgery when applicable. 

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