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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 3-8

Antifibrinolyticin reducing postoperative blood loss in total hip replacement and its effect on coagulation profile: A prospective randomized study


1 Department of Orthopedics, GGS Medical College, Faridkot, Punjab, India
2 Department of Orthopedics, Gian Sagar Medical College, Banur, Punjab, India
3 Department of Radiodiagnosis, GGS Medical College, Faridkot, Punjab, India

Date of Web Publication14-Jun-2018

Correspondence Address:
Dr. Anshul Dahuja
GGS Medical College, Faridkot, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joas.joas_2_18

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  Abstract 


BACKGROUND: Studies have shown that tranexamic acid reduces blood loss and transfusion need in patients undergoing total hip arthroplasty. However, till date, no study has been large enough to determine definitively whether the drug is safe and effective in total hip arthroplasty. We examined whether intravenous tranexamic acid, when compared with placebo, is safe and effective in total hip arthroplasty.
MATERIALS AND METHODS: A prospective, randomized, double blinded study was conducted in a group of 142 patients undergoing total hip arthroplasty divided equally into tranexamic acid group and control group. Our protocol included administration of one dose of 15 mg/kg of TXA (given as infusion over 15 min ) in 100 ml NS just 15 min before incision and the subsequent 8 hourly in TXA group. In control group we have given 100 ml normal saline infusion just before operation and 100 ml NS infusion 8 hourly for 2 days postoperatively. Postoperative blood parameters were recorded.
RESULTS: The total postoperative drain output and transfusion requirement was found to be lower in patients who received TXA (352-412 ml) as compared to control group (804-878 ml). We have observed 3 and 4 cases of DVT in TXA and control group respectively. Coagulation profile is least affected in both the groups.
CONCLUSION: We conclude that tranexamic acid significantly reduces postoperative blood loss and transfusion requirements during total hip arthroplasty.

Keywords: Blood loss, blood transfusion, total hip arthroplasty, tranexamic acid


How to cite this article:
Dahuja A, Bhowmik S, Kaur R, Shayam R, Jindal S. Antifibrinolyticin reducing postoperative blood loss in total hip replacement and its effect on coagulation profile: A prospective randomized study. J Orthop Allied Sci 2018;6:3-8

How to cite this URL:
Dahuja A, Bhowmik S, Kaur R, Shayam R, Jindal S. Antifibrinolyticin reducing postoperative blood loss in total hip replacement and its effect on coagulation profile: A prospective randomized study. J Orthop Allied Sci [serial online] 2018 [cited 2018 Sep 25];6:3-8. Available from: http://www.joas.in/text.asp?2018/6/1/3/234467




  Introduction Top


Total hip arthroplasty is associated with extensive postoperative blood loss.[1],[2],[3],[4],[5],[6],[7] In the literature studied, mean postoperative blood loss in total hip replacement(THR) was found to vary from 0 to 880ml and mean total blood loss by 530–1100ml.[8],[9],[10] Increased plasma concentrations of coagulation factors, reduced concentration of coagulation inhibitors, enhanced platelet activity, endovascular release of catecholamines, and serotonin contribute to hemostasis.[8] The fibrinolytic system is activated when tissue trauma releases tissue plasminogen activator(t-PA).[4],[5],[6] Thrombin also activates fibrinolysis by triggering release of t-PA from the vascular endothelial cells. Surgical stress enhances the release of plasmin at the site of vascular damage.[6] This may contribute to blood loss after total hip arthroplasty although after surgery, the fibrinolytic system shuts down as a consequence of increased release of plasminogen activator inhibitor that inactivates t-PA [6],[7],[8],[9],[10]

Multiple techniques can be used to reduce the risk of perioperative allogenic blood transfusion in THR surgery such as preoperative autologous blood donation, intra-and postoperative red blood cell salvage, controlled hypotension, normovolemic hemodilution, or lowering the transfusion trigger. These techniques have several disadvantages, and they are time consuming, expensive devices are needed, or the poor quality blood quality increases, especially if using postoperatively salvaged but untreated blood.[11] Tranexamic acid(TXA), a synthetic inhibitor of fibrinolysis, competitively blocks a lysine binding site of plasminogen. Plasminogen–TXA complexes redisplaced from the surface of fibrin and as plasmin is prevented from binding to fibrinogen or fibrin monomers, lysis is delayed. At higher concentrations, TXA also acts as a noncompetitive inhibitor of plasmin.[4],[5] Although significant reductions in blood loss and transfusion requirements are very consistent in TXA trials for total knee replacement, the results observed in trials for THR show a much greater discrepancy.[12],[13],[14],[15],[16],[17],[18] To be effective, the intravenous prophylactic administration of TXA in THR must be made at the beginning of, and not after, the surgical procedure,[17],[18] but the wide variability in administration regimens in terms of both dose and duration is a source of concern among orthopedic surgeons.

Despite various studies proving the efficacy of TXA(antifibrinolytic) with single or multiple boluses of different sizes with or without subsequent infusions, no consensus has been reached on the dose of TXAto be administered or duration of treatment.[2],[13],[14],[15] Claeys et al.[19] postulated that there was no effect on the intraoperative blood loss because TXAdelayed lysis of the fibrin clot by the proteolytic action of plasmin, rather than by influencing primary hemostasis and coagulation. He also suggested that a dose of 10mg/kg would not be sufficient to prevent postoperative bleeding and that higher doses would be required to be effective. However, with a larger dose of 20mg/kg, the plasma level is maintained for 8 h, which may have the potential to cause prothrombotic complications.[20] The half-life of 1g of intravenously administered TXAhas been found to be 1.9h, and plasma concentrations remain above the minimum therapeutic level for up to 4 h.[21],[22] Three previous studies have investigated the use of a single preoperative dose of 1g of TXA, and while they have shown a reduction in postoperative blood loss, the sample size was small, the reduction in blood transfusion and cost-benefit were not investigated, and there was no routine investigation for thromboembolism(TE).[14],[23],[24]

Many studies showed effectiveness of TXA in THA, but no study discussed its effect on coagulation profile. Despite these promising results, valid data on safety are lacking, as large sample sizes are needed to determine this outcome. Thus, concerns about the routine use of TXA remain.

In this study, we have investigated that in patients undergoing total hip arthroplasty, administration of a high dose of TXAfor 3days influences blood loss and whether it has a blood sparing effect along with that we did venography to rule out TE. We also assessed the mechanism of action and effect of TXAon coagulation.


  Materials and Methods Top


From May 2010 to July 2015, 142adult patientsundergoing unilateral primary THR under combined spinal epidural anaesthesia gave informed consent to participate in a double-blind study with a prior randomization. Exclusion criteria were revision THR, a history of venous or arterial TE, thrombophilia, ischemic heart disease, malignancy, a history of epilepsy, and severe chronic renal insufficiency, defined as an estimated glomerular filtration rate>30mg albumin per gram creatinine in the urine using the modification of diet in renal disease formula. The prospective study was approved by the institutional ethics committee, and written informed consent was obtained from each patient.

A simple randomization schedule using random numbers generated by Microsoft Excel (Microsoft Corp, Redmond, WA) was employed, and after patient eligibility had been confirmed by the anesthetist, the patients were allocated to a group randomized through envelopes opened at anaesthesia induction with 71patients in TXAgroup (T group) and 71patients in control group(C group). The anesthetist was blinded to treatment allocation, as he received the medication from a study nurse, who had prepared the medication before the operation. The operating surgeons were also blinded to the type of TXAtreatment. Our protocol included administration of one dose of 15mg/kg of TXA (given as infusion over15min) in 100ml normal saline(NS) just 15min before incision and the subsequent 15mg/kg dose 8 hourly for 48hpostoperatively in tranexamic group. In control group, we have given 100ml NS infusion just before operation and 100ml NS infusion 8 hourly for 2days postoperatively. At the time of postoperative evaluation, neither the patients nor the authors were aware of the group assignments.

Preoperative investigations included hemoglobin(Hb), hematocrit(Hct), a complete coagulogram, liver function tests, renal function test, and routine preanesthetic checkup. Postoperative Hb levels, Hct, and D-dimer were measured 6 h, 24h after surgery, and at the time of discharge(6–10days). Anegative suction drain was kept for 48h, and drain output was recorded for day 0 and 1. Blood transfusion in the form of pack cell volume was given to all patients with Hb<9gm/dl or postoperative drain output>500ml in first 24h.

All the operations involved the use of a conventional stemmed unilateral THR performed by a single surgeon through posterior approach. Cemented, uncemented, and hybrid THRs were used depending on bone stock and age of the patient. The method of anaesthesia was either spinal epidural with or without an indwelling catheter or spinal or epidural only, according to the anesthetist's preference. Two negative suction drains(subfascial and subcutaneous) were used in all cases to measure postoperative blood loss and hidden subfascial blood loss.

Postoperative use of deep vein thrombosis(DVT) stockings, ankle pumps, and early mobilization was ensured as a part of thromboprophylaxis. Venous color Doppler was performed at the time of discharge to rule out DVT.

Parameter tests of significance(independent t-test) were used for statistical analysis. Power analysis was also done, and a P <05 was taken as statistically significant.


  Results Top


The study consists of 142cases of THR having 71patients both in control and TXAgroup. As far as number, age, sex ratio, and diagnosis are concerned, our study is well matched [Flowchart 1].



Mean age of the patients undergoing THR was 61.5years and 60years in TXAand control group, respectively. Male to female ratio is 7:5 in both the groups. Duration of surgery was 100min(86–120) for control group as compared to 94(81–112) min for TXAgroup.

The mean preoperative Hb and pre-and postoperative Hct values were found to be similar in both the groups. Postoperative Hb was found to be significantly lower in the control group as compared to the TXAgroup(P=0.001) and having high power(996).

The total postoperative drain output was found to be lower in patients who received TXA(352–412ml) as compared to control group(804–878ml), and this relation was found to be significant with high power concluding a decrease in total blood loss in patients who were administered TXAduring total hip arthroplasty.

Above results showed a direct effect on blood transfusion requirement, i.e., tranexamic: control=1:2.9.

The preoperative andpostoperative platelet count were found to be similar in both the groups with a consistent nonsignificant reduction as shown in [Table1].
Table 1: Showing demographic and statistical data of control and tranexamic acid group

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The preoperative fibrinogen levels were almost similar, but postoperatively after 2days, they were 623mg/dl (589–657mg/dl) in the tranexamic group whereas 577mg/dl(545–599mg/dl) in the control group.

The D-dimer levels after 2days postoperatively were within normal range but found to be higher normal in control group372 mg/dl(350–380 mg/dl) than tranexamic group308 mg/dl(302–322 mg/dl).

No adverse effects such as nausea, vomiting, or hypersensitivity were found in any of the patient receiving TXA.

Seven patients(3 in tranexamic group and 4 in control group) developed superficial wound infection for which extended course of antibiotics was given.

Two patients in control group and 1patient in tranexamic group developed deep infection requiring repeated debridement.

In our study, we found 7 and 5cases of DVT in control and TXAgroup. There were no thromboembolic complications in both the groups.


  Discussion Top


The fact that the study was automatically well matched with strong homogeneity of the preoperative data added strength to our study. Various antifibrinolytic agents such as aprotinin, e-aminocaproic acid, and TXAcan help reduce blood loss in THA. Of these, TXAis preferred as it is cheaper and less allergenic than aprotinin and is more potent than e-aminocaproic acid.[17] We have evaluated the use of TXAgiven during total hip arthroplasty and for the first 48h after operation. TXAdecreases blood loss and significantly reduced transfusion requirements. The blood-sparing effect of TXAwas most evident during the first 24h after operation when blood loss was significantly reduced compared with the control group as shown by the drain output. During surgery, the acetabulum is reamed, and the femoral shaft is broached and washed with NaCl under pulsatile pressure. During this period, there is no time for clot formation. This may explain why most authors find no significant reduction in perioperative blood loss.[12],[15],[16] That is why we just focused on postoperative blood loss. Measurement of postoperative blood loss can also differ depending on the number of drains used postoperatively.

In order to decrease the risk of infection, surgical drains are now removed more rapidly, or a smaller number of drains are placed. The hidden blood loss in hematomas could also add to the discrepancy between the lack of difference in postoperative blood loss and the reduction of patients requiring red blood cell transfusion inTXA-treated patients although studies have shown that the hidden blood loss in THR surgery is small.[19],[20]

Fibrinolytic activation is a cascade process that is most easily inhibited in its earlier phase, which may explain why TXAhas little effect when given after heavy blood loss.[19],[20] TXAinhibits clot lysis more efficiently when administered before clot formation than after the fibrin clot is formed. Once plasminogen is bound to the fibrin surface, TXAis no longer effective.[25] This may explain why TXAhas little effect when administered at the end of surgery. Benoni e tal. found no significant reduction in postoperative blood loss in total hip arthroplasty when TXAwas given toward the end of surgery and that is why we preferred to give TXAjust before surgery and then postoperatively.[13]

We found that early blood loss(within 6h) and total blood loss were significantly reduced in the TXAgroup. Again, this was consistent with the findings of previous studies and supported the hypothesis that TXAinduces inhibition of early fibrinolysis before the body's usual response after 24h.[14],[23],[24]

We kept the blood transfusion limit with Hb<9gm/dl or drain output>500ml. This study demonstrates that transfusion requirements also reduced in the TXAstudy group which is comparable with the previous conducted studies.[19],[26]

Despite the efficacy of TXAfor reducing bleeding, no direct correlation was found between blood loss and variables of fibrinolysis(D-dimer). TXA-treated patients showed no bleeding tendency.

We also found increased concentration of D-dimer in the control group during the first 2days after operation indirectly support the antifibrinolytic effect of TXA. We did not encounter any increase in thromboembolic activity with TXA. Even a meta-analysis found no increase of thromboembolic complications with the use of TXAin total hip and knee replacement surgery.[26] Benoni et al. suggest that TXAis not associated with an increase in venous thromboembolic events because the effect of TXAis more pronounced in operative wounds than in the peripheral venous blood.[27] He also suggested that TXAdoes not affect risk of DVT because it inhibits fibrinolysis in the wound not in circulation. Previous research on TXAand thrombosis failed to show any thrombogenic effect,[27] but thrombotic complications were reported with therapy exceeding 24h.[28] Our data also showed that TXAdoes not induce platelet activation as platelet count was similar in both the groups postoperatively, and this finding is consistent with the earlier studies.[29]

Limitations of the study include involvement of different anesthetist, different surgeons, different indications for surgery and only postoperativeblood loss and postoperative blood transfusion taken into account but still major issues being taken into consideration while performing this study.


  Summary Top


Hence, we conclude that TXAgiven for 48h after operation is effective in reducing blood loss and transfusion needs after prosthetic hip surgery. Adose of 15mg/kg just before operation followed by maintenance dose of 15 mg/kg every 8 h for 24 h would seem appropriate as longer administration of TXA is not accompanied by further reduction in blood loss.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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