Moran Jay, Kahan Joseph B, Morris Jensa, Joo Peter Y, O'Connor Mary I
Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA.
Center for Musculoskeletal Care and Yale New Haven Health, Yale School of Medicine, New Haven, CT, USA.
Geriatr Orthop Surg Rehabil. 2022 Aug 31;13:21514593221124414. doi: 10.1177/21514593221124414. eCollection 2022.
The timing of tranexamic acid (TXA) administration in fragility hip fracture patients is controversial. Prior studies have demonstrated reduction in transfusion requirements using the two-dose arthroplasty model. However, unlike arthroplasty patients whose bleeding starts at the time of surgical incision, hip fractures have an onset of bleeding at the time of the injury. The primary goal of this study was to evaluate the optimal timing of TXA administration and to determine its effect on red blood cell transfusions in fragility hip fracture patients.
All patients admitted to the fragility hip fracture service from April 1, 2019 to September 30, 2019 were prospectively screened for inclusion in the study. Eligible patients received 4 intravenous doses of TXA: Ineligible patients received no TXA. Patients with medical conditions precluding the use of TXA were deemed ineligible: allergy to TXA; creatinine clearance <30 mL/min; active malignancy; vascular event in the past year; anticoagulant use; fracture >48 hours prior to presentation. A subset of patients received only admission TXA dosing and a separate subset of patients received only incision and post op TXA dosing. Red blood cell transfusions, major adverse vascular events, and minor drug and infusion-related adverse events were recorded for all subgroups of patients.
A total of 508 patients were eligible for analysis. In total, 180 patients received no TXA, 32 patients only received the admission doses of TXA, 112 patients received only the arthroplasty based (incision and post op) doses of TXA, and 183 patients received all 4 doses of TXA. The transfusion rate was significantly lower in patients who received all 4 doses of TXA (8.7%) and in those who only received one dose of TXA at admission (9.4%) compared to patients who received TXA at incision and recovery room (25.7%) or those patients who did not receive TXA prophylaxis (29.4%) (P = 0.001). Additionally, the transfusion rate for intramedullary nailing was higher compared to patients undergoing any other procedure (27% vs 13.8%, P < 0.001).
Patients with fragility hip fractures who received IV TXA at hospital admission have significantly lower transfusion rates compared to those who received no tranexamic acid or those who received two dose-TXA (at the operative incision and in the post-operative recovery room). These findings suggest that isolated dosing of TXA at hospital admission may be more effective at reducing post-operative bleeding than the traditional arthroplasty dosing (incision and post-op doses) and is equally as effective as the 4-dose TXA protocol in hip fracture patients undergoing surgery.
氨甲环酸（TXA）在脆性髋部骨折患者中的给药时机存在争议。先前的研究表明，使用两剂量关节置换模型可减少输血需求。然而，与手术切口时开始出血的关节置换患者不同，髋部骨折在受伤时就开始出血。本研究的主要目的是评估TXA给药的最佳时机，并确定其对脆性髋部骨折患者红细胞输血的影响。
对2019年4月1日至2019年9月30日收治的所有脆性髋部骨折患者进行前瞻性筛查，以纳入本研究。符合条件的患者接受4次静脉注射TXA；不符合条件的患者不接受TXA。因医疗状况而不能使用TXA的患者被视为不符合条件：对TXA过敏；肌酐清除率<30 mL/分钟；活动性恶性肿瘤；过去一年内发生血管事件；使用抗凝剂；就诊前骨折>48小时。一部分患者仅接受入院时的TXA给药，另一部分患者仅接受切口和术后TXA给药。记录所有患者亚组的红细胞输血、主要不良血管事件以及轻微的药物和输液相关不良事件。
共有508例患者符合分析条件。总共有180例患者未接受TXA，32例患者仅接受入院时的TXA剂量，112例患者仅接受基于关节置换（切口和术后）的TXA剂量，183例患者接受了全部4剂TXA。与在切口和恢复室接受TXA的患者（25.7%）或未接受TXA预防的患者（29.4%）相比，接受全部4剂TXA的患者（8.7%）和仅在入院时接受一剂TXA的患者（9.4%）的输血率显著较低（P = 0.001）。此外，与接受任何其他手术的患者相比，髓内钉固定的输血率更高（27%对13.8%，P < 0.001）。
与未接受氨甲环酸或接受两剂量TXA（手术切口时和术后恢复室）的脆性髋部骨折患者相比，入院时接受静脉注射TXA的患者输血率显著较低。这些发现表明，在入院时单独给予TXA在减少术后出血方面可能比传统的关节置换给药（切口和术后剂量）更有效，并且与接受4剂TXA方案的髋部骨折手术患者同样有效。
