Tranexamic acid in hip hemiarthroplasty

Conrad Lee, Richard Freeman, Mark Edmonson, Ben Rogers

Does it reduce blood loss and transfusion rates

Background

• Hip surgery is associated with intraoperative blood loss 1, 2

• Post operative anaemia have a negative impact on functional recovery 2

• Blood transfusion has associated high costs and risks 3

• Hip fracture patients are most affected by postoperative anaemia 2

Background

• Several blood conservation methods 4

• Tranexamic acid (TXA) – antifibrinolytic– Prevents conversion of plasminogen to plasmin– Half-life 180 mins– Most effective when given before hyperfibinolysis cased by

tissue injury during surgery – 1g given intravenously as prophylaxis in RSCH (based on surgeon

preference)

• Much evidence for TXA use in elective THR / TKR 5, 6

Aim

• Does prophylactic TXA given before incision reduce postoperative transfusion requirement in hip hemiarthroplasty?

• Does it reduce postoperative haemoglobindrop?

Methods

Consecutive hip hemiarthroplasties for fractures

(June 2013 – Nov 2014)

Retrospective cohort study

Exclusion • Blood transfusion within

3 days pre-op• Incomplete data• Austin Moore prosthesis

Data collected• Demographics (age, gender, length of stay)• Pre-morbid (mobility, AMTS, residence, antiplatelet/anticoag use)• Surgery (ASA, anesthetic type, approach, surgeon grade)• Bloods (pre / post op Hb)• Transfusion requirements • Mortality and morbidity

• Electronic records

• National Hip Fracture Database

• Patient notes

PRIMARY OUTCOMEBlood (RBC) transfusion within 14 days of surgery

SECONDARY OUTCOMESSignificant reduction in haemoglobin (>20g/L) on day 1 post op

Clinical thromboembolic event 30 and 90 day mortality

Results

305 Hip hemi

271 eligible cases 186 female, 85 male

Mean age 85

34 cases exclude:

• 18 Austin Moore• 10 Incomplete data• 6 Pre-operative blood

transfusion

CASE (TXA)N = 84

31%

CONTROL (No-TXA)N = 187

69%

CASE (TXA)N = 84

31%

CONTROL (No-TXA)N = 187

69%

Cases matched:Age, gender, mean pre-operative Hb, antiplatelet use, anticoagulation use, pre-morbid residency, mobility, preoperative AMTS, anesthetic type, ASA grade, surgical approach, surgeon grade*

22

62

hb drop>20

hb drop<20

79

108

26%(n = 22)

42%(n = 79)

P= 0.01

Day 1 Hb reduction

6%(n = 5)

18%(n = 35)

P= 0.01

RBC Transfusion

(n = 40)

Avg. no of units per patient2.6 2.2

P= 0.43

1 in 161 in 5

21 + 15.49 18 + 18.05P= 0.26

Length of stay(days)

DVT /PE

Mortality

1 4P= 1.00

5% (n =4) 5% (n =9)P= 1.00

10% (n =8) 10% (n =19)P= 1.00

30 days

90 days

NNT = 8

1g TXA£ 1.50

1 Unit RBC£ 124.85

X-match£ 15.97

~ £ 6312.62 saved per annumif all patients given TXA

Discussion

• Data supports prior literature on blood conservative benefits of TXA 5, 6

• Controversial safety profile 7

• Low VTE rates, mortality as surrogate

• Slight higher use of TXA in trauma fellows cases (14%)

• Limitations– ?Selection bias

Conclusion

• TXA reduces postoperative Hb drop and transfusion requirements in hip hemiarthroplasties

• TXA is safe and cost effective

• Prophylactic TXA is recommended for patients undergoing hip hemiarthroplasties

References

1. Zufferey PJ, Miquet M, Quenet S, Martin P, Adam P, Albaladejo P, et al. Tranexamic acid in hip fracture surgery: a randomized controlled trial. Br J Anaesth [Internet]. 2010 Jan [cited 2015 Feb 2];104(1):23–30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19926634

2. Lawrence VA, Silverstein JH, Cornell JE, Pederson T, Noveck H, Carson JL. Higher Hb level is associated with better early functional recovery after hip fracture repair. Transfusion [Internet]. 2003 Dec [cited 2015 Feb 2];43(12):1717–22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14641869

3. Kadar A, Chechik O, Steinberg E, Reider E, Sternheim A. Predicting the need for blood transfusion in patients with hip fractures. Int Orthop [Internet]. 2013 Apr [cited 2015 Feb 4];37(4):693–700. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3609993&tool=pmcentrez&rendertype=abstract

4. Lemaire R. Strategies for blood management in orthopaedic and trauma surgery. J Bone Joint Surg Br [Internet]. 2008 Sep [cited 2015 Feb 2];90(9):1128–36. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18757950

5. Poeran J, Rasul R, Suzuki S, Danninger T, Mazumdar M, Opperer M, et al. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ [Internet]. 2014 Jan 12 [cited 2014 Dec 7];349(aug12_8):g4829. Available from: http://www.bmj.com/content/349/bmj.g4829

6. Zhou X, Tao L, Li J, Wu L. Do we really need tranexamic acid in total hip arthroplasty? A meta-analysis of nineteen randomized controlled trials. Arch Orthop Trauma Surg [Internet]. 2013 Jul [cited 2015 Jan 4];133(7):1017–27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23615973

7. Ho KM, Ismail H. Use of intravenous tranexamic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: a meta-analysis. Anaesth Intensive Care [Internet]. 2003 Oct [cited 2015 Jan 29];31(5):529–37. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14601276