Comparison of Intravenous, Topical or Combined Routes of Tranexamic Acid Administration in Patients Undergoing Total Knee and Hip Arthroplasty: a Meta-analysis of Randomised Controlled Trials

Overview

Journal BMJ Open

Specialty General Medicine

Date 2019 Jan 31

PMID 30696680

Citations 35

Authors

Qi Sun

Jinyu Li

Jiang Chen

Chenying Zheng

Chuyin Liu

Yusong Jia

Affiliations

Soon will be listed here.

Abstract

Objective: This study aimed to compare the effects of intravenous, topical and combined routes of tranexamic acid (TXA) administration on blood loss and transfusion requirements in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Design: This was a meta-analysis of randomised controlled trials (RCT) wherein the weighted mean difference (WMD) and relative risk (RR) were used for data synthesis applied in the random effects model. Stratified analyses based on the surgery type, region, intravenous and topical TXA dose and transfusion protocol were also conducted. The main outcomes included intraoperative and total blood loss volume, transfusion rate, low postoperative haemoglobin (Hb) level and postoperative Hb decline. However, the secondary outcomes included length of hospital stay (LOS) and/or occurrence of venous thromboembolism (VTE).

Setting: We searched the PubMed, Embase and Cochrane CENTRAL databases for RCTs that compared different routes of TXA administration.

Participants: Patients undergoing TKA or THA.

Interventions: Intravenous, topical or combined intravenous and topical TXA.

Results: Twenty-six RCTs were selected, and the intravenous route did not differ substantially from the topical route with respect to the total blood loss volume (WMD=30.92, p=0.31), drain blood loss (WMD=-34.53, p=0.50), postoperative Hb levels (WMD=-0.01, p=0.96), Hb decline (WMD=-0.39, p=0.08), LOS (WMD=0.15, p=0.38), transfusion rate (RR=1.08, p=0.75) and VTE occurrence (RR=1.89, p=0.15). Compared with the combined-delivery group, the single-route group had significantly increased total blood loss volume (WMD=198.07, p<0.05), greater Hb decline (WMD=0.56, p<0.05) and higher transfusion rates (RR=2.51, p<0.05). However, no significant difference was noted in the drain blood loss, postoperative Hb levels and VTE events between the two groups. The intravenous and topical routes had comparable efficacy and safety profiles.

Conclusions: The combination of intravenous and topical TXA was relatively more effective in controlling bleeding without increased risk of VTE.

Citing Articles

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References

Digas G, Koutsogiannis I, Meletiadis G, Antonopoulou E, Karamoulas V, Bikos C . Intra-articular injection of tranexamic acid reduce blood loss in cemented total knee arthroplasty. Eur J Orthop Surg Traumatol. 2015; 25(7):1181-8. DOI: 10.1007/s00590-015-1664-8. View

Drosos G, Ververidis A, Valkanis C, Tripsianis G, Stavroulakis E, Vogiatzaki T . A randomized comparative study of topical versus intravenous tranexamic acid administration in enhanced recovery after surgery (ERAS) total knee replacement. J Orthop. 2016; 13(3):127-31. PMC: 4821446. DOI: 10.1016/j.jor.2016.03.007. View

Wang Z, Shen X . The efficacy of combined intra-articular and intravenous tranexamic acid for blood loss in primary total knee arthroplasty: A meta-analysis. Medicine (Baltimore). 2017; 96(42):e8123. PMC: 5662361. DOI: 10.1097/MD.0000000000008123. View

Zhang L, Ma J, Kuang M, Zhao J, Wang Y, Lu B . Comparison of oral versus intravenous application of tranexamic acid in total knee and hip arthroplasty: A systematic review and meta-analysis. Int J Surg. 2017; 45:77-84. DOI: 10.1016/j.ijsu.2017.07.097. View

Dunn C, Goa K . Tranexamic acid: a review of its use in surgery and other indications. Drugs. 1999; 57(6):1005-32. DOI: 10.2165/00003495-199957060-00017. View

Yang L, Du S, Sun Y . Is combined topical and intravenous tranexamic acid superior to single use of tranexamic acid in total joint arthroplasty?: A meta-analysis from randomized controlled trials. Medicine (Baltimore). 2017; 96(30):e7609. PMC: 5627839. DOI: 10.1097/MD.0000000000007609. View

Zhang L, Ma J, Kuang M, Zhao J, Lu B, Wang Y . The efficacy of tranexamic acid using oral administration in total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res. 2017; 12(1):159. PMC: 5658985. DOI: 10.1186/s13018-017-0660-6. View

Sukeik M, Alshryda S, Haddad F, Mason J . Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement. J Bone Joint Surg Br. 2011; 93(1):39-46. DOI: 10.1302/0301-620X.93B1.24984. View

Aglietti P, Baldini A, Vena L, Abbate R, Fedi S, Falciani M . Effect of tourniquet use on activation of coagulation in total knee replacement. Clin Orthop Relat Res. 2000; (371):169-77. DOI: 10.1097/00003086-200002000-00021. View

10.

Pundir V, Pundir J, Georgalas C, Fokkens W . Role of tranexamic acid in endoscopic sinus surgery - a systematic review and meta-analysis. Rhinology. 2013; 51(4):291-7. DOI: 10.4193/Rhino13.042. View

11.

Gomez-Barrena E, Ortega-Andreu M, Padilla-Eguiluz N, Perez-Chrzanowska H, Figueredo-Zalve R . Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial. J Bone Joint Surg Am. 2014; 96(23):1937-44. DOI: 10.2106/JBJS.N.00060. View

12.

Rasouli M, Maltenfort M, Erkocak O, Austin M, Waters J, Parvizi J . Blood management after total joint arthroplasty in the United States: 19-year trend analysis. Transfusion. 2016; 56(5):1112-20. DOI: 10.1111/trf.13518. View

13.

Moher D, Liberati A, Tetzlaff J, Altman D . Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009; 6(7):e1000097. PMC: 2707599. DOI: 10.1371/journal.pmed.1000097. View

14.

Adler Ma S, Brindle W, Burton G, Gallacher S, Hong F, Manelius I . Tranexamic acid is associated with less blood transfusion in off-pump coronary artery bypass graft surgery: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth. 2010; 25(1):26-35. DOI: 10.1053/j.jvca.2010.08.012. View

15.

Wong J, Abrishami A, El Beheiry H, Mahomed N, Davey J, Gandhi R . Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg Am. 2010; 92(15):2503-13. DOI: 10.2106/JBJS.I.01518. View

16.

Shemshaki H, Nourian S, Nourian N, Dehghani M, Mokhtari M, Mazoochian F . One step closer to sparing total blood loss and transfusion rate in total knee arthroplasty: a meta-analysis of different methods of tranexamic acid administration. Arch Orthop Trauma Surg. 2015; 135(4):573-88. DOI: 10.1007/s00402-015-2189-7. View

17.

Wu Y, Zeng Y, Yang T, Si H, Cao F, Shen B . The Efficacy and Safety of Combination of Intravenous and Topical Tranexamic Acid in Revision Hip Arthroplasty: A Randomized, Controlled Trial. J Arthroplasty. 2016; 31(11):2548-2553. DOI: 10.1016/j.arth.2016.03.059. View

18.

Ugurlu M, Aksekili M, Caglar C, Yuksel K, Sahin E, Akyol M . Effect of Topical and Intravenously Applied Tranexamic Acid Compared to Control Group on Bleeding in Primary Unilateral Total Knee Arthroplasty. J Knee Surg. 2016; 30(2):152-157. DOI: 10.1055/s-0036-1583270. View

19.

Begg C, Mazumdar M . Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994; 50(4):1088-101. View

20.

Jadad A, Moore R, Carroll D, Jenkinson C, Reynolds D, Gavaghan D . Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials. 1996; 17(1):1-12. DOI: 10.1016/0197-2456(95)00134-4. View