Shock/sepsis/trauma/critical careThe use of tranexamic acid to reduce blood loss and transfusion in major orthopedic surgery: a meta-analysis
Introduction
Major orthopedic procedures including total knee arthroplasty, total hip arthroplasty, and spinal surgery are associated with significant blood loss [1]; therefore, allogenic blood transfusion is a common requirement. However, it carries the risk of immunological and nonimmunological adverse effects, such as a higher rate of postoperative infection, intravascular hemolysis, transfusion-induced coagulopathy, renal impairment or failure, and even increased mortality [2]. Numerous strategies, including autologous blood donation, autologous drain transfusion, regional anesthesia, and acute normovolemic hemodilution, have been used to reduce allogenic blood transfusion rates. However, their application is limited by their clinical and financial efficacy [3].
Tranexamic acid (TXA), a synthetic derivative of lysine, competitively blocks lysine-binding sites on plasminogen, thus reducing the local degradation of fibrin by plasmin [4]. TXA has been used successfully to stop bleeding in multiple specialties including liver, cardiac, prostate, and dental surgeries [5], [6], [7], [8]. Numerous studies have investigated their efficacy in reducing blood loss and transfusion requirements in patients undergoing orthopedic surgery with varying results [9]. Thus, we conducted a meta-analysis of randomized controlled trials to assess the effectiveness and safety of TXA in reducing blood loss and transfusion requirements in major orthopedic surgery including knee, hip, and spinal procedures.
Section snippets
Study design
This review was based on Cochrane methodology for conducting meta-analyses. All data were reported according to the Quality of Reporting for Meta-analyses, by the Handbook for Systematic Reviews of Interventions (Version 5.0.0) [10].
Search methodology
We sought published randomized controlled trials that evaluated TXA in patients undergoing orthopedic surgery. The published literature was searched from 1966 to April 2013 using MEDLINE, PubMed, EMBASE, and Cochrane Database of Systematic Reviews. Search terms
Results
According to the inclusion and exclusion criteria, we identified 46 randomized controlled trials associated with orthopedic surgery [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58] (Fig. 1). A total of 11 studies involved total hip arthroplasty, four studies involved total
Discussion
Significant blood loss and risk involved in blood transfusion are important features that must be considered in orthopedic surgery. Several methods have been reported to reduce blood loss and blood transfusion after surgery. Techniques, such as autologous blood transfusion, intraoperative hemodilution, hypotensive anesthesia, and modified use of the drain, increase costs and pose additional logistical problems, and may also be immunomodulatory.
TXA is a synthetic derivative of lysine, that
Conclusions
TXA significantly reduced intraoperative, postoperative, and total blood loss and transfusion requirements in patients undergoing major orthopedic surgery. At the same time, the TXA does not increase the prevalence of DVT. However, given the heterogeneity of the pooled estimates and low number of studies included, larger studies are required to examine blood loss, transfusion, and thromboembolic complications in the use of TXA in orthopedic procedures.
Acknowledgment
This work was supported by the grant from Anhui Medical University (No. 2013xkj045). All authors report no conflicts of interest.
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These authors contributed equally to this work and should be considered as co-first authors.