For orthopedic surgery, is tranexamic acid standard for pre- and peri-operative anticoagulation?

Department of Hematology/Medical Oncology at the Cleveland Clinic in Cleveland, Ohio

This month, Anne T. Neff, MD, answers a question about tranexamic acid for pre- and peri-operative anticoagulation.

CLINICAL DILEMMA

I have seen several orthopedic surgeons give tranexamic acid before and during surgery. One surgeon did not even hold the warfarin. Is this the standard now?

EXPERTS MAKE THE CALL

I would never pretend to know the standard approach among orthopedic surgeons, but I have observed the same practices. Most large-joint orthopedic surgeries (hip or knee joint replacement) are complicated by significant blood loss and the need for allogeneic blood transfusions to treat symptomatic post-operative anemia. Transfusion, in turn, is associated with other complications such as wound infections and inflammation.

To curb blood loss, many major orthopedic procedures now include intravenous or topical use of tranexamic acid, a lysine analog that competitively inhibits the activation of plasminogen to plasmin, thus decreasing fibrinolytic activity. Tranexamic acid has been very successful at decreasing blood loss and the need for transfusion and, subsequently, lowering the risk of post-operative anemia.

Fortunately, this has not come at the price of increased venous thromboembolism – a significant potential threat to any major joint surgery. Anticoagulation with tranexamic acid is still instituted in the standard fashion. Because of the potential risk of increased vascular occlusion, the major trials of tranexamic acid in orthopedic surgeries have barred the participation of patients with a history of venous or arterial thrombosis.1 In a trial of trauma patients where no such exclusions were made, there was no increased incidence of thrombosis in the patients who received tranexamic acid;2 therefore, in my consulting practice, I have recommended against it only with very hypercoagulable patients.

References

  1. Kim C, Park SS, Davey JR. Tranexamic acid for the prevention and management of orthopedic surgical hemorrhage: current evidence. J Blood Med. 2015;6:239-44.
  2. CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376:23-32.

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