Minimizing bleeding and transfusion is desirable given its cost, complexity and potential
for adverse events. Concerns have been heightened by recent data demonstrating that
bleeding events may predict worse outcomes and by warnings about the safety of erythropoietic
stimulating agents. Prior small studies suggest that antifibrinolytic agents may reduce
bleeding and transfusion need in patients undergoing total hip replacement (THR) or
total knee arthroplasty (TKA). However, no single study has been large enough to definitively
determine if these agents are safe and effective. To address this issue we performed
a systematic review of randomized trials describing the use of tranexamic acid, epsilon
aminocaproic acid, or aprotinin administration in the perioperative setting.
MEDLINE, EMBASE, CINAHL and the Cochrane databases were searched for relevant trials.
Two independent reviewers abstracted total blood loss, transfusion requirements, and
venous thromboembolism (VTE) rates. Data were combined using the Mantel-Haenszel method
and dichotomous data expressed as relative risk (RR) with 95% confidence intervals
(CI).
Patients receiving antifibrinolytic agents had reduced transfusion need (RR 0.52;
95% CI, 0.42 to 0.64; P<0.00001), reduced blood loss and no increase in the risk of
VTE (RR 0.95% CI, 0.80 to 1.10, I(2)=0%, P=0.531).
We conclude that antifibrinolytic agents may reduce bleeding and transfusion in patients
undergoing THR or TKA who receive appropriate antithrombotic prophylaxis. There is
a need for a large, adequately powered prospective study to carefully examine the
safety and efficacy of these agents.