| Summary: | 碩士 === 國立陽明大學 === 護理學系 === 107 === Degenerative arthritis is considered to be an inevitable disease with aging. Knee replacement can solve the pain and activity-restricted symptoms caused by knee joint degeneration, but there will be a lot of bleeding during the total knee arthroplasty (TKA) and blood transfusion is needed. However, bleeding and blood transfusions may present some potential risks. Tranexamic acid (TXA) is a synthetic antifibrinolytic agent. In recent years, studies have suggested using more than 2g of high-dose TXA, which is more effective in controlling bleeding after TKA. There is no comprehensive systematic review to compare the clinical efficacy of high-dose and low-dose TXA in controlling bleeding after TKA. The purpose of this study was to use a systematic review of the literature to investigate patients undergoing TKA with high or low doses of TXA for blood transfusion rates, total blood loss, total drain output, maximum hemoglobin (Hb) drop, and the incidence of deep vein thrombosis.
We conducted a systematic search of PubMed, EBSCO (Medline, CINAHL, Academic search complete-ACS), Embase, Cochrane Library Central Register of Controlled Trials, Taiwan Journal Paper Index System, National Digital Library of Theses and Dissertations in Taiwan and Chinese Electronic Periodical Services (CEPS) for English and Chinese language studies and subsequently by searching the bibliographies of all relevant retrieved articles that were published before October 31, 2018. The following search terms were used on combination with Boolean operators AND or OR: “tranexamic acid” AND “total knee arthroplasty“ OR “total knee replacement“ OR “knee replacement arthroplasties“ OR “knee prosthesis“. By appraising the methodological quality, 21 randomized control trials that had been published between 2010 and 2017 were used for this meta-analysis. Totally there are 1249 patients in high dose TXA group and 920 in low dose group.
In this study, there was no significant difference in terms of reducing the number of patients transfused when comparing high dose TXA group with low dose TXA group (RR: 0.74, 95% CI: 0.52 to 1.07, p= 0.11, I2= 0%), but the high doses of TXA significantly reduces total blood loss (MD: -115.12, 95% CI: -168.81 to -61.42, p< 0.001, I2= 81%), total drain output (MD: -51.31, 95% CI: -81.75 to -20.87, p= 0.001, I2= 91%) and maximum Hb drop (MD: -0.43, 95% CI: -0.80 to -0.05, p= 0.02, I2= 94%), then without an apparent increase in thromboembolic complication (RR: 0.54, 95% CI: 0.26 to 1.10, p= 0.09, I2= 0%). A single injection of high dose TXA compared with low dose TXA, cannot effectively reduce blood transfusion rate, total drain output (MD: -18.03, 95% CI: -61.09 to 25.04, p= 0.41, I2= 94%), and maximum Hb drop (MD: 0.12, 95% CI: -0.18 to 0.42, p= 0.44, I2= 55%), however, the commutative high-dose TXA from three consecutive injections can effectively reduce the blood transfusion rate compared with low-dose TXA (RR: 0.40, 95% CI: 0.16 to 0.99, p= 0.05, I2 = 0%) ). Current meta-analysis evidence suggests that the use of intravenous or combined intravenous and local injections to accumulate higher doses of TXA can reduce blood transfusion rate, total blood loss, total drainage output, and hemoglobin decline. Considering the pharmacokinetics of TXA, we recommend that the first dose of TXA was administered before surgery, a second locally injected dose before wound closure, or 1-2 intravenous doses at an interval of three hours.
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