4. Discussion
blood loss, postoperative blood loss, TKA, trauma
WORLD WAR II, POSTOPERATIVE COMPLICATIONS, BLOOD LOSS, BLOOD CLOTS, COMPLICATION, BLEEDING REQUIRING TRANSFUSION
Making every effort to improve the reduction in blood loss during and after surgical procedures is a fundamental aspect of all surgeries. According to Gao et al., IV TXA has shown a potential association with reduced blood transfusion requirements and higher hemoglobin levels in patients undergoing TKA. Importantly, this benefit was observed without an increase in the incidence of postoperative complications compared to the use of topically applied fibrin sealants. Moreover, there was no significant difference noted in the total calculated blood loss between the two groups [The findings from our prospective randomized controlled trial indicated that the incidence of blood transfusion was zero in both the combined Tisseel@ + IV TXA group and the IV TXA-only group. In the Tisseel@ + TXA group, the average estimated blood loss was 0.463 ± 0.2422 L, which was comparable to the TXA group’s value of 0.455 ± 0.2522 L. Additionally, postoperative calculated blood loss was comparable between the two groups, with values of 0.259 ± 0.1 L and 0.268 ± 0.108 L, respectively. These results suggest that no synergistic effect was observed when adding fibrin sealants (Tisseel@) to IV TXA in patients undergoing TKA. The absence of statistically significant differences in estimated total blood loss and calculated total blood loss between the two groups may be further clarified by examining Cohen’s d. The effect size is negligible and reinforces the idea that the addition of Tisseel@ may not provide a meaningful advantage over IV TXA in the context of blood conservation during TKA.The primary objective of achieving ERAS for TKA is to implement a multimodal approach that minimizes surgical-related trauma and stress. This approach involves employing the least invasive surgical techniques and practices. Nevertheless, the reduction in blood loss during and after surgical procedures is one of the key elements of ERAS. Proper intraoperative management significantly contributes to ensuring safety, minimizing blood loss, and promoting early recovery. In the American College of Surgeons’ National Surgical Quality Improvement Program database, bleeding requiring transfusion was the most common complication in TKA patients who failed the ERAS protocol [TXA is a synthetic anti-fibrinolytic medication that acts as a competitive inhibitor, specifically blocking the lysine-binding sites of plasminogen, plasmin, and tissue plasminogen activator. By doing so, TXA effectively retards the process of fibrinolysis and prevents the breakdown of blood clots [The utilization of fibrin sealants, which are created by mixing plasma fibrinogen with thrombin, was initially reported during World War II [In the current study, only a single dosage of the fibrin sealant Tisseel@ was used in our trial. According to a meta-analysis published by Yang et al., the dosages in nine randomized control trials and four prospective comparative studies ranged from 2 mL to 10 mL of fibrin sealant. Their conclusion was that the utilization of fibrin sealant may lead to a reduction in the transfusion rate and the number of transfusion units required after TKA. However, the impact in terms of reducing the total blood loss was not significant [Our study has several limitations. First, the sample size in each group was relatively small. Nevertheless, in numerous prospective randomized controlled trials examining the variance in postoperative blood loss after TKA between groups, significant findings have been observed with fewer than 50 patients in each group [