Shock/sepsis/trauma/critical care
The use of tranexamic acid to reduce blood loss and transfusion in major orthopedic surgery: a meta-analysis

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Abstract

Background

Conflicting reports have been published regarding the effect of tranexamic acid (TXA) on reducing blood loss and transfusion in patients undergoing orthopedic surgery. We performed a meta-analysis to evaluate the effectiveness and safety of TXA treatment in reducing blood loss and transfusion in major orthopedic surgery.

Materials and methods

MEDLINE, PubMed, EMBASE, and Cochrane databases were searched for relevant studies. Only randomized controlled trials were eligible for this study. The weighted mean difference in blood loss, number of transfusions per patient, and the summary risk ratio of transfusion and deep vein thrombosis (DVT) were calculated in the TXA-treated group and the control group.

Results

A total of 46 randomized controlled trials involving 2925 patients were included. The use of TXA reduced total blood loss by a mean of 408.33 mL (95% confidence interval [CI], −505.69 to −310.77), intraoperative blood loss by a mean of 125.65 mL (95% CI, −182.58 to −68.72), postoperative blood loss by a mean of 214.58 mL (95% CI, −274.63 to −154.52), the number of blood transfusions per patient by 0.78 U (95% CI, −0.19 to −0.37), and the volumes of blood transfusions per patient by 205.33 mL (95% CI, −301.37 to −109.28). TXA led to a significant reduction in transfusion requirements (relative risk, 0.51; 95% CI, 0.46–0.56), and no increase in the risk of DVT (relative risk, 1.11; 95% CI, 0.69–1.79).

Conclusions

TXA significantly reduced blood loss and blood transfusion requirements in patients undergoing orthopedic surgery, and did not appear to increase the risk of DVT.

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.

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