Effect of tranexamic acid use on blood loss and thromboembolic risk in hip fracture surgery: systematic review and meta-analysis

Abstract

Introduction:

Intravenous tranexamic acid (IV TXA) is a recognised pharmaceutical intervention utilised to minimise blood loss and allogenic blood transfusion. However, the use of IV TXA in hip fracture surgery remains inconclusive. We conducted a meta-analysis to investigate the role of TXA in operative hip fracture management on operative and total blood loss, allogenic blood transfusion requirements and impact on venous thromboembolic (VTE) event incidence.

Methods:

A systematic computerised literature search of PubMed, Medline, Embase, Ovid, The Cochrane Controlled Trials Register, Trip and Google was conducted. We reviewed the efficacy of IV TXA on perioperative blood loss, total blood loss, pre- and postoperative haemoglobin differences, duration of surgery, allogenic blood transfusion requirements and VTE events.

Results:

8 studies were eligible including 6 randomised control trials and 2 cohort studies. Patients receiving IV TXA had reduced mean total blood loss of 442.9 mls (95% CI, 426.5-459.3; p<0.00001), reduced operative blood loss of 88.5 mls (95% CI, 59.9-117.2; p<0.00001), a decrease in the need for allogenic blood transfusion (OR 0.37; 95% CI, 0.26-0.53; p<0.00001) and a reduction in pre- and postoperative haemoglobin difference (p = 0.013.) There was no significant increase in VTE risk (OR 1.59; 95% CI 0.67-3.75; p>0.29) or significant difference on duration of surgery seen with IV TXA usage (p>0.06).

Conclusions:

Our review demonstrated the efficacy of IV TXA in minimising perioperative, reducing total blood loss and lowering the necessity for allogenic blood transfusions with no significant increased risk in VTE events.

Keywords

Blood loss Hip fracture Thromboembolism Tranexamic acid Transfusion

Get full access to this article

View all access options for this article.

References

Hernlund

Svedbom

Ivergård

et al . Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos. 2013;8(1-2):136.

Burge

Worley

Johansen

Bhattacharyya

Bose

. The cost of osteoporotic fractures in the UK: projections for 2000–2020. J Med Econ. 2001;4(1-4):51-62.

Maxwell

White

. Anaesthetic management of patients with hip fractures: an update. Continuing Education in Anaesthesia Critical Care & Pain. 2013;13(5):179-183.

National Clinical Guideline Centre. CG124: The management of hip fracture in adults Produced by the National Clinical Guideline Centre. Health Technol Assess (Rockv). 2011:68-81.

Foss

Kehlet

. Hidden blood loss after surgery for hip fracture. J Bone Joint Surg Br. 2006;88(8):1053-1059.

Lawrence

Silverstein

Cornell

Pederson

Noveck

Carson

. Higher Hb level is associated with better early functional recovery after hip fracture repair. Transfusion. 2003;43(12):1717-1722.

Klein

Spahn

Carson

. Red blood cell transfusion in clinical practice. Lancet. 2007;370(9585):415-426.

Carson

Altman

Duff

et al . Risk of bacterial infection associated with allogeneic blood transfusion among patients undergoing hip fracture repair. Transfusion. 1999;39(7):694-700.

Willems

de Craen

AJM

Nelissen

RGHH

van Luijt

Westendorp

RGJ

Blauw

. Haemoglobin predicts length of hospital stay after hip fracture surgery in older patients. Maturitas. 2012;72(3):225-228.

10.

Fergusson

Hébert

Mazer

et al . BART Investigators. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med. 2008;358(22):2319-2331.

11.

Bennett

Klingenberg

Langholz

Gluud

. Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2014;11(11):CD006640.

12.

Sundström

Seaman

Kieler

Alfredsson

. The risk of venous thromboembolism associated with the use of tranexamic acid and other drugs used to treat menorrhagia: a case-control study using the General Practice Research Database. BJOG. 2009;116(1):91-97.

13.

Moher

Liberati

Tetzlaff

Altman

. PRISMA Group. Reprintpreferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Phys Ther. 2009;89(9):873-880.

14.

Moher

Cook

DJJ

Eastwood

Olkin

Rennie

Stroup

DFF

. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet. 1999;354(9193):1896-1900.

15.

Pluye

Robert

Cargo

et al . Mixed methods appraisal tool for systematic mixed studies reviews. Montréal: McGill University. 2011;(Part I):1-8. http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/84371689/MMAT 2011 criteria and tutorial 2011-06-29updated2014.08.21.pdf. Accessed July 01, 2016.

16.

Pluye

Hong

. Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews. Annu Rev Public Health. 2014;35(1):29-45.

17.

Higgins

JPT

Altman

Gotzsche

et al . The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.

18.

Sterne

Hernán

Reeves

et al . ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.

19.

Higgins

Altman

. Assessing risk of bias in included studies. In: Higgins

Green

, eds. Cochrane handbook for systematic reviews of interventions. Cochrane Book Series. John Wiley & Sons. 2008;187-241.

20.

Hozo

Djulbegovic

Hozo

. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005;5(1):13.

21.

Zufferey

Miquet

Quenet

et al . Tranexamic acid in hip-fracture surgery (THIF) study. Tranexamic acid in hip fracture surgery: a randomized controlled trial. Br J Anaesth. 2010;104(1):23-30.

22.

Sadeghi

Mehr-Aein

. Does a single bolus dose of tranexamic acid reduce blood loss and transfusion requirements during hip fracture surgery? A prospective randomized double blind study in 67 patients. Acta Med Iran. 2007;45(6):437-442.

23.

Vijay

Bedi

Mitra

Das

. Role of tranexamic acid in reducing postoperative blood loss and transfusion requirement in patients undergoing hip and femoral surgeries. Saudi J Anaesth. 2013;7(1):29-32.

24.

Emara

Moez

Elkhouly

. Topical versus intravenous tranexamic acid as a blood conservation intervention for reduction of post-operative bleeding in hemiarthroplasty. Anesth Essays Res. 2014;8(1):48-53.

25.

Tengberg

Foss

Palm

Kallemose

Troelsen

. Tranexamic acid reduces blood loss in patients with extracapsular fractures of the hip: results of a randomised controlled trial. Bone Joint J. 2016;98-B(6):747-753.

26.

Lee

Freeman

Edmondson

Rogers

. The efficacy of tranexamic acid in hip hemiarthroplasty surgery: an observational cohort study. Injury. 2015;46(10):1978-1982.

27.

Shiva

Sundar

. Effect of the Tranexamic Acid in Reducing the Blood Loss in the Orthopaedic Surgery. IOSR J Dent Med Sci. 2015;14(2):22-26.

28.

Mohib

Rashid

Ali

Zubairi

Umer

. Does tranexamic acid reduce blood transfusion following surgery for inter-trochanteric fracture? A randomized control trial. J Pak Med Assoc. 2015;65(11)(Suppl 3):S17-S20.

29.

Sukeik

Alshryda

Haddad

Mason

. Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement. J Bone Joint Surg Br. 2011;93(1):39-46.

30.

Alshryda

Sukeik

Sarda

Blenkinsopp

Haddad

Mason

. A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. Bone Joint J. 2014;96-B(8):1005-1015.

31.

Ker

Edwards

Perel

Shakur

Roberts

. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ. 2012;344:e3054.

32.

Farrow

Smith

Ashcroft

Myint

. A systematic review of tranexamic acid in hip fracture surgery. Br J Clin Pharmacol. 2016;82(6):1458-1470.

33.

Desai

Wood

Marsh

et al . Factors affecting transfusion requirement after hip fracture: can we reduce the need for blood? Can J Surg. 2014;57(5):342-348.

34.

Wang

Jiang

Marshall

Zhang

. Arthroplasty or internal fixation for displaced femoral neck fractures: which is the optimal alternative for elderly patients? A meta-analysis. Int Orthop. 2009;33(5):1179-1187.

35.

Giancola

Antonini

Delle Rose

Crippa

. Percutaneous compression plating versus gamma nail for the treatment of pertrochanteric hip fractures. Strateg Trauma Limb Reconstr. 2008;3(1):9-14.

36.

Foulongne

Gilleron

Roussignol

Lenoble

Dujardin

. Mini-invasive nail versus DHS to fix pertrochanteric fractures: a case-control study. Orthop Traumatol Surg Res. 2009;95(8):592-598.

37.

Harrington

Nihal

Singhania

Howell

. Intramedullary hip screw versus sliding hip screw for unstable intertrochanteric femoral fractures in the elderly. Injury. 2002;33(1):23-28.

38.

Mannucci

Levi

. Prevention and treatment of major blood loss. N Engl J Med. 2007;356(22):2301-2311.

39.

Parker

Khan

RJK

Crawford

Pryor

. Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients. J Bone Joint Surg Br. 2002;84(8):1150-1155.

40.

Zhang

Hua

Cai

. A comparison of regional and general anaesthesia for total replacement of the hip or knee: a meta-analysis. J Bone Joint Surg Br. 2009;91(7):935-942.