1. Medication Utilization Evaluation (MUE)
MultiCare Health System (MHS)
Topical Tranexamic Acid
DATE SUBMITTED: November4,2014
ASPECT OF CARE: Reviewof appropriatenesssurroundingthe use andprescribingof topical tranexamic acid(TXA) in
orthopedicsurgery
WHYIS THIS IMPORTANT?: The MHS Pharmacyand TherapeuticsCommitteeapprovedthe additionof TXA tothe
formularyona restrictedbasisinMay 2013. This syntheticaminoacidderivative reducesthe breakdownof hemostati c
fibrinbyplasmin. IV administrationof TXA hasbeenshowntodecrease bleedinginorthopedicsurgeries. The IV
administrationof TXA wasassessedatAllenmore Hospital andresultsindicatednopatientharmandlow use of
transfusion. There isinterestinthe use of topical TXA for the same indicationstoavoidsystemicuse of TXA. ThisMUE
will assessthe use of topical TXA forsafetyandefficacyandresultswill be comparedtothose fromthe IV TXA MUE
completedinMarch 2014.
INDICATORS TO BE ANALYZED:
1. Appropriate patient/use:
 Topical tranexamicacid use restrictedtototal hip/knee arthroplasty
 Patientsathighriskfor significantsurgical bloodloss,asdefinedbyall patientsundergoingprimaryand
revisiontotal jointsurgery
2. DosingRecommendations:
Topical tranexamic acid (TXA) for highbleedrisk total joint surgerypatients
TKA: 1 gram tranexamicacidin20 mL NS fortopical application
Followingfinal irrigation,TXA solutionwill be appliedwithknee broughtintoextensionpriortowound
closure.Woundwill be bathedwithsolutionfor2 - 5 minutes;anyexcessfluidwill thenbe suctionedto
allowforjointclosure.Nofurtherwoundwashoutwill occurfollowingapplicationof tranexamicacid.
THA: 3 grams tranexamicacidin60 mL NS fortopical application
Approximately20mL of TXA solutionwill be usedtobathe the acetabulumfollowingpreparation,just
priorto impactingthe shell.Approximately20mL of TXA solutionwill be placedwithinthe femoral
canal afterfinal broaching.Followingreductionof the final hipcomponentsandfinal irrigation,the
remainingsolution(approximately20mL) will be appliedpriortowoundclosure. Woundwill be bathed
withsolutionfor2 - 5 minutes;anyexcessfluidwill be suctionedtoallow forjointclosure.Nofurther
woundwashoutwill occurfollowingapplicationof tranexamicacid.
3. Additional outcomes:
 Bloodtransfusion occurrence
 Post-opvenous thromboembolism(VTE) incidence
 FacilityandSurgeon
 Lengthof stay(LOS)
 Timingof dose
 Total patientcosts/chargesforhospital stay
RESULTS: A retrospectivechartreviewwasconductedfor surgical patientstreatedwith topical TXA fromJuly 8th
,2014
to October7th
, 2014 at Multicare GoodSamaritanHospital (GSH) to ensure appropriate use followingP&Tapproval.
Patientsundergoingtotal jointsurgeryatGSH were reviewedweeklytomonitorfortopical TXA administration. Patients
were selectedtobe includedinthe review if theyreceivedthe drugduring surgery. Patientswere followedtothe

2. completion theirinitialfollow-upvisitinorderto more accurately rule outthe occurrence of post-operative DVT. All
patientsincludedin thisreviewwere treatedby orthopedicservicesat GSH.
Patients and Demographics
Topical TXA IV TXA (From March MUE)
Facility Good SamaritanHospital: 100%
(42/42)
AllenmoreHospital: 100% (42/42)
Surgeon MD #1 59.5% (25/42) MD #1 76.2% (32/42)
MD #2 33.3% (14/42) MD #2 16.8% (7/42)
MD #3 7.2% (3/42) MD #3 4.7% (2/42)
MD #4 2.3% (1/42)
Sex(female) 64.3% (27/42) 62% (26/42)
Age (average in years) 65.1 64.5
Weight(average in kg) 97.83 96.36
Patients>100 kg 45.2% (19/42) 52% (22/42)
Total Hip Replacement 40.5% (17/42, one bilateral repair
and one revision)
28.6 % (12/42)
Total Knee Replacement 59.5% (25/42, one bilateral repair
and one revision)
71.4% (30/42) (2 bilateral knees)
Results
Topical TXA IV TXA (From March MUE)
Documentedas High Risk for a bleed 92.9% (39/42) 0% (0/42)
History of a bleed 4.8% (2/42) 2.4% (1/42) (hematuria)
On anticoagulation therapy
31.0% (13/42 = 2 takingclopidogrel,6
takinglow dose aspirin,and 5 taking
warfarin)
33.3% (14/42 = 1 clopidogrel daily,7
takinglow dose aspirin,and6 taking
scheduledNSAIDs)
Hepatic Dysfunction
2.4% (1/42, chronicalcoholicliver
dysfunction)
11.9% (5/42 = 4 were alcoholicsor
had elevatedenzymesfromalcohol)
Appropriate Dose Administered(see
above)
97.6% (41/42, one patient
undergoingbilateral THA received3g
of topical TXA dividedequally
betweentwojointsinsteadof 3g
topical TXA for eachjointseparately.
Two casesreceivedthe appropriate
dose accordingto the MAR, but the
surgeonsdictatedadifferent,
incorrectamounthad beengivenin
the procedure notes)
52% (22/42) were dosedaccording
to recommendeddose of 10mg/kg
to a max of 1g. (Inthisreview,all
patientswere given1gregardlessof
weight)
Appropriate Timing of Administration
100% (42/42, all surgeonsdictatedin
the procedure notesthe time of
administration,whichwaspriorto
woundclosure inall instances)
Patientsrequiringblood transfusions
2.4% (1/42, intensivehiprevision
requiringtransfusionwith2units
intra-operatively)
4.8% (2/42)
Post-opIncidence of VTE 7.2 % (3/42) 0% (0/42)
Length of Stay (average days) 2.71 2.74
Average Total PatientCharge For
Hospital Stay
$96,586 $100,399.61

3. DISCUSSION:
1. Documentation: Duringthe initial 2monthsof data collection,anERXfortopical TXA didnotexistandnurses
had to documentadministrationsunderthe entry“unidentifiedmedication.” Asaresult,there wasinconsistent
documentationof dose quantityandadministrationinthe MAR. Due to knowledge of the subject,pharmacy
servicesdiligentlytrackedthe dosesthatwere senttopatientoperatingrooms. A new ERX became availablefor
topical TXA in September;however,there isstill inconsistencyinMARdocumentationdue tosome employees
continuingtouse the “unidentifiedmedication”entryinEPIC.
2. Outcomes:
a. Transfusions: One patient(2.4%) undergoingtotal jointsurgeryrequired atransfusion,versus4.8%of
patientsinthe IV TXA review. The transfusionoccurredintra-operativelyasaresultof a difficulttotal hip
revision. Furthertransfusionpost-operativelywasnotrequired. The national average followinghipandknee
procedureshasbeenreportedtobe around37%. Otherarticlesreference rates inthe 16-20% range. Since
January2012, transfusionratesatGSH hasaveraged14.9%.
b. VTE: Three of the 42 patientstreatedwith topical TXA experiencedavenousthromboembolismduringtheir
hospital stay,ascomparedto 0 patientsdevelopingaVTEin the IV TXA review. Case 1was complicatedbya
pneumoniaandprolongedhospital stayrequiringadmissiontoinpatientrehabilitation. The patientremained
largelyimmobile andsubsequentlydevelopedaDVT. Case 2 developedaDVT15 dayspost-opdespite adequate
anticoagulationwithwarfarin. The patient’shistorywassignificantforDVTpostprostate surgeryyearsbefore.
Case 3 developedaDVT/PE13 dayspost TKA despite phenomenalwarfarinmanagement.
c. LOS and patient charges: The average lengthof staywas 2.71 days andpatientcharge on average was
$96,586. These figuresare comparable tothe resultsof anIV TXA MUE performedinMay 2014 that foundthe
average lengthof stayfor patientstobe 2.74 days and average patientcharge tobe $100,399.61. Hospital cost
of 1g of TXA is $44.39. Statisticsonlengthof stayand total hospital chargeswill be continue tobe valuablefor
future comparisons.
RECOMMENDATIONS:
 Topical TXA displayssimilarresultstoIV TXA. The resultsof thisMUE show only milddifferencesbetween
topical andIV TXA use. The mostnotable difference isthe occurrence of 3 DVTsin the topical cohortvs. 0
DVTs inthe IV cohort;however,there are importantconfoundersinthe 3cases of DVTs followingtopical
TXA use. The incidence of transfusionbetweenbothgroupsisalsocomparable.
 Establishconsistentdocumentation foradministration. Thisiscurrentlyinprogress. Pharmacyhas
informednursingof the appropriate entrytouse forMAR documentation. The “TranexamicAcidfor
irrigation”ERXwill be usedinlieuof the “unidentifiedmedication”entryforMARadministration
documentation.
o Dose and Timingof AdministrationinProcedure Notes:Overall,surgeonsdocumentedthe timingof
topical TXA administrationconsistently;however,some surgeonsincorrectlydictatedthe dose that
was given. The timingof administrationwill be the onlyinformationrequiredforinclusioninto
procedure notes,withdose informationtobe excluded.
 Provide educationtoMultiCare orthopedicsurgeons. Provide anddiscussMUE resultswiththe orthopedic
group.
 Re-reviewthe dataandliterature overthe nextyear. ThisMUE showed similarresultstoIV TXA use inthe
area of transfusionrate,at2.4% vs.4.8%. VTE occurred in3 patients(7.2%) followingtopical TXA use,
whereas0 patientsdevelopedaVTEin the IV TXA review. Inthe future,collectionof pre andpostsurgical
hemoglobinandhematocritvalueswouldprove tobe useful comparatorsof therapeuticresponse. Itwould
alsobe importantand informative if dataonTXA use is comparedtoan MHS baseline patientgroupwhodid
not receive TXA toidentifynotable differences. New literature alsocontinuestobe publishedsurrounding
the use of antifibrinolyticagentsinsurgeries,andasa healthsystemwe needtofrequentlyreevaluate our
processestooptimize therapy. Forexample,atrial directlycomparingTXA toaminocaproicacid,amuch
cheapermedicationat$1.96 per dose,issetto release resultswithinthe yearonhow these medications
compare in termsof effectiveness,safety,andcostanalysiswhenusedintotal knee andhiparthroplasty
(ClinicalTrials.govIdentifier:NCT02030821).

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 More referencesavailable uponrequest
Submittedby:Max Whitney,PharmD