Current Concepts in Joint Replacement Winter Meeting

Current Concepts in Joint Replacement Winter Meeting

Issue: February 2012
February 01, 2012
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Tranexamic acid, giving fluids first reduce the need for transfusion in arthroplasty

Issue: February 2012
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Administering fluids first rather than transfusing patients and using an antifibrinolytic agent such as tranexamic acid can reduce blood loss and the need for transfusion in patients undergoing hip or knee arthroplasty, according to a presentation at the Current Concepts in Joint Replacement 2011 Winter Meeting.

“Minimizing blood loss is, of course, desirable as is minimizing transfusion,” Mark W. Pagnano, MD, said during his presentation. “Blood transfusion markedly slows rehabilitation and hospital discharge, and it has a psychological impact on our patients. In addition, it exposes each of those patients to substantial risks.”

An average blood loss of 1,000 mL is typical, resulting in a 3 g drop in hemoglobin and a need for blood transfusion, Pagnano said. There is a 10% to 20% increase in cost with a blood transfusion during joint arthroplasty and a 20% to 25% increase in length of stay, he said.

Pagnano said the key to minimizing blood loss is to change the surgical thinking to “give patients fluid first and red blood cells only later.”

“Most of the postoperative clinical symptoms that you and I have traditionally attributed to anemia are, in fact, a volume problem, not a red blood cell problem,” Pagnano said. “Our traditional indicators of the need for transfusion — hypotension, elevated heart rates and low urine output — these almost always respond to IV fluids alone and do not need blood most of the time. Most of our patients can function quite safely with relatively low hemoglobins, if they have sufficient intravascular volume. There is comprehensive ICU [intensive care unit] data that morbidity for patients is only increased with very, very low hemoglobins in the 6 or under range.”

Another way to reduce blood loss and the need for transfusion is using an antifibrinolytic medication such as tranexamic acid or aminocaproic acid. These medications are easy to obtain, inexpensive and have a long history of use in cardiac and dental surgery and tonsillectomy, Pagnano said. Of the two medications, Pagnano recommends tranexamic acid because of extensive studies in patients undergoing total knee or total hip procedures proving its ability to decrease blood loss and transfusion. The medication has not been associated with higher rates of deep vein thrombosis or pulmonary embolism. It costs $60 per gram and one-tenth of that cost in Europe, Pagnano said.

“It works by inhibiting the activation of plasminogen to plasmin, thus preventing the breakdown of fibrin,” Pagnano said.

At his institution, patients are administered one gram of tranexamic acid mixed with 50 mL of saline through an IV preoperatively at the time of prophylactic antibiotics and another gram mixed with 50 mL of saline at wound closure. Pagnano also does not require pre-donation of blood or hemoglobin screening. He advises against using tranexamic acid if patients have had a recent cardiac stent.

“The benefit to you and me as orthopedic surgeons if we limit transfusion is a grateful set of patients who progress faster through all phases of recovery after their hip or knee arthroplasty,” Pagnano said. – by Renee Blisard

Reference:
  • Pagnano M. Minimizing blood loss: An acid trip in 2011. Paper #38. Presented at the Current Concepts in Joint Replacement 2011 Winter Meeting. Dec. 7-10. Orlando, Fla.
  • Mark W. Pagnano, MD, can be reached at the Mayo Clinic, 200 First St. SW, Rochester, MN 55944; 507-284-5276; email: pagnano.mark@mayo.edu.
  • Disclosure: Pagnano receives royalties from Depuy and MAKO Surgical Group, and is a consultant for Stryker Orthopaedics.