Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation.
OBJECTIVE
Tranexamic acid (TXA) therapy can reduce red blood cell (RBC) transfusion; however, this therapy remains underutilized in many surgical patient populations. We assessed whether implementation of a protocol to facilitate universal administration of TXA in patients undergoing total hip or knee arthroplasty would reduce the incidence of RBC transfusion without increasing adverse clinical outcomes.


METHODS
We implemented a quality of care policy to provide universal administration of intravenous TXA at a dose of 20 mg·kg(-1) iv to all eligible patients undergoing total hip or knee arthroplasty from October 21, 2013 to April 30, 2014. We compared data from an equal number of patients before and after protocol implementation (n = 422 per group). The primary outcome was RBC transfusion with secondary outcomes including postoperative hemoglobin concentration (Hb) and length of hospital stay. Adverse events were identified from the electronic medical records. Data were analyzed by a Chi square test and adjusted logistic and linear regression analysis.


RESULTS
Implementation of the protocol resulted in an increase in TXA utilization from 45.8% to 95.3% [change 49.5%; 95% confidence interval (CI), 44.1 to 54.5; P < 0.001]. This change was associated with a reduction in the rate of RBC transfusion from 8.8% to 5.2%, (change -3.6%; 95% CI, -0.1 to -7.0; P = 0.043). Pre- and post-protocol mean [standard deviation (SD)] Hb values were similar, including the nadir Hb prior to RBC transfusion [72 (8) g·L(-1) vs 70 (8) g·L(-1), respectively; mean difference -1 g·L(-1); 95% CI, -3 to 5; P = 0.569]. Length of stay was not altered, and no increase in adverse events was observed.


CONCLUSIONS
Implementation of a perioperative TXA protocol was associated with both an increase in TXA use and a reduction in RBC transfusion following hip or knee arthroplasty. Adverse events and length of hospital stay were not influenced by the protocol.
Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.
James E
JE
Baker
St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.|Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
Katerina
K
Pavenski
Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.
Razak A
RA
Pirani
Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.
Alexander
A
White
Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.
Mark
M
Kataoka
Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
James P
JP
Waddell
Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.
Alexander
A
Ho
Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
Emil H
EH
Schemitsch
Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.
Nick
N
Lo
Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
Earl R
ER
Bogoch
Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.
Antoine
A
Pronovost
Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.|Ontario Transfusion Coordinators (ONTraC), Toronto, ON, Canada.
Katherine
K
Luke
Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.|Ontario Transfusion Coordinators (ONTraC), Toronto, ON, Canada.
Alanna
A
Howell
Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.|Ontario Transfusion Coordinators (ONTraC), Toronto, ON, Canada.
Anna
A
Nassis
Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
Albert K Y
AK
Tsui
Department of Pharmacy, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
Rosa Maria
RM
Tanzini
Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.
Robisa
R
Pulendrarajah
Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.|Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
C David
CD
Mazer
St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada.|Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
John
J
Freedman
Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. hareg@smh.ca.|St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, ON, Canada. hareg@smh.ca.|Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. hareg@smh.ca.
Gregory M T
GM
Hare
D000368:Aged; D000933:Antifibrinolytic Agents / Q000627:therapeutic use*; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D016063:Blood Loss, Surgical / Q000517:prevention & control; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014148:Tranexamic Acid / Q000627:therapeutic use*
D000933:Antifibrinolytic Agents; D014148:Tranexamic Acid