Tranexamic Acid Uses in Primary Hip and Knee Arthroplasty

Abstract

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.