• Tranexamic Acid Administration in Knee and Hip Arthroplasty: A Clinical Practice Guideline

      Jaladanki, Jahnavi (2017)
      Tranexamic acid (TXA) is an anti-fibrinolytic agent that has been shown to decrease blood loss and transfusion requirements during hip and knee replacements. The purpose of this Doctorate Nursing Practice (DNP) Scholarly Project is to develop and evaluate a clinical practice guideline (CPG) for the safe and efficacious administration of TXA in hip and knee arthroplasty. A CPG was created and revised with the aid of a multi-disciplinary subject matter expert (MSME) group. The DNP students presented a draft of the CPG along with graded evidence based on current literature to the stakeholders on the team. Following the meeting, an online version of the AGREE II Instrument was distributed to the MSME group to critique and appraise the CPG. The AGREE II tool was designed to evaluate the methodological rigor in guideline development. Following the AGREE II analysis and revisions to the CPG, the guideline was approved by the Chief Anesthesiologist at the institution and was presented to the entire anesthesia department for future implementation. Following this presentation, the Practitioner Feedback Questionnaire (PFQ) was distributed and collected in an anonymous manner. The PFQ analysis revealed that 100% of the end users agreed that there is a strong need for the CPG; however, it was noted that 9% of the end users strongly disagreed that the CPG would be used in their practice. New practice guidelines frequently experience resistance to change by end-users. Further end-user clinical development should focus on educating staff on evidence-based practice as the literature continues to expand.
    • Tranexamic Acid Uses in Primary Hip and Knee Arthroplasty

      Kesselman, Rita; Amos, Veronica Y. (2019-05)
      Background: Over 300,000 total hip and knee replacement surgeries are done in the United States on an annual basis. The average total blood loss for primary total knee arthroplasty was 762-1789 mL, and 1200-2100 mL for primary total hip arthroplasty. This required 25-30% of patients to receive a transfusion of at least one unit of packed red blood cells. Blood transfusions are associated with longer hospital stays, higher morbidity and mortality rates, transfusion reactions and the transmission of infections. Tranexamic acid is an antifibrinolytic that is known to reduce blood loss. Local Problem: Stakeholders in a large inner-city tertiary medical center requested a doctoral student to revise the current clinical practice guideline based on the most recent evidence-based literature review. Interventions: A literature review of four articles was conducted to reassess contraindications, timing, dosages, and routes of administration of tranexamic acid for total knee arthroplasty and total hip arthroplasty. The reviewed articles were published between 2016 and 2018. The collected data was evaluated and presented to the organization. Results: The final clinical practice guideline included a purpose, target audience, inclusion and exclusion criteria and recommendation for administration. Inclusion and exclusion criteria had five absolute contraindications and four relative contraindications for tranexamic acid administration. Recommendation for administration included oral and intravenous methods. Conclusions: The revised clinical practice guideline on tranexamic acid administration for primary hip and knee arthroplasty patients provides clear guidance about the contraindications of tranexamic acid administration based on the most recent evidence-based literature review. The revised clinical practice guideline was approved and added to the hospital-wide clinical practice guideline database under anesthesia, bleeding, procoagulant and orthopedic surgery. Laminated pamphlets with tranexamic acid contraindications were placed in patient care areas that utilize tranexamic acid most often. Recommendations were made to continue data collection related to blood transfusion rates post hip and knee arthroplasty patients who receive the new dosage of tranexamic acid, as well as complication rates based on the new contraindication lists. Continuous review of the literature on the topic should guide future clinical practice guideline revisions.
    • The Use of Tranexamic Acid in Gynecologic and Oncology Surgery

      Giba, Joseph; Amos, Veronica Y. (2019-05)
      Background: Gynecologic surgery encompasses many surgical approaches, some of which are associated with considerable perioperative blood loss, blood transfusion administration, and increased morbidity and mortality. Similarly, women undergoing surgery for gynecologic cancer need to have as many tumors removed as possible, which can become major abdominal surgery with massive blood loss and blood transfusions required. It is widely known perioperative blood transfusions are associated with increased adverse events, potentially causing life-threatening complications. The purpose of this Doctor of Nursing Practice scholarly project was to develop a clinical practice guideline governing the use of tranexamic acid in the gynecologic and oncology surgery population to decrease the amount of perioperative blood loss and incidence of blood transfusions, further decreasing morbidity and mortality. Local Problem: Leadership at the highest level of the institution requested that a tranexamic acid protocol be developed for several surgical populations where it could prove beneficial. There was a difference among providers on the correct dosing of tranexamic acid, when to administer the medication, and the precautions and contraindications concerning its use. Interventions: A literature review was performed including systematic reviews, randomized control trials, and existing clinical practice guidelines. This literature was summarized to develop the clinical practice guideline. Institutional stakeholders utilized the Appraisal of Guidelines for Research and Evaluation Tool to assess the rigor of the guideline and provided feedback on guideline development. The guideline was then presented to anesthesia department staff during a weekly meeting, after which staff completed the Provider Feedback Questionnaire to evaluate the potential use of the guideline at the institution. Results: Results from each tool were collected and descriptive statistics were calculated. The overall domain rating score based on Appraisal of Guidelines for Research and Evaluation Tool results was 79%, while both stakeholders approved the guideline with modifications. For the Provider Feedback Questionnaire, 95% of anesthesia department staff agreed they would both “apply the recommendations to my patients” as well as “use it in my own practice” if the guideline was approved. Conclusions: Tranexamic acid is a safe and effective drug for gynecologic and oncology surgery that can decrease the amount of perioperative blood loss and incidence of blood transfusions. The dosing, timing of administration, and contraindications can potentially be implemented at other institutions and for other surgical populations to provide safer care to patients.