Aminocaproic Acid (Amicar) vs Aminocaproic Acid (Amicar) vs. Tranexamic Acid (TXA) In Relation to Hypotension in Total Hip & Knee Replacement Patients  Stephanie Marx, RN, Clinical Nurse Mary Ann Petri, MSN, RN, CNS Karen Bialas, MS, BSN, RN, CNML, VP Nursing, CNO Aurora Medical Center Washington County  Wisconsin Association of Clinical Nurse Specialists CNO/CNS/Shared Governance Breakfast September 6th, 2019

Background and Significance ~To Nursing and Shared Governance~ Orthopedic surgeries are associated with an increased risk of blood loss.  Transfusion related complications, limited blood supply, and health care costs (Falana & Patel, 2014). Antifibrinolytic drugs control blood loss and prevent transfusion related complications Patients receiving TXA have less blood loss compared to the patients that received Amicar (Boese, Centeno, & Walters, 2017).  The difference in blood loss was not considered significant Minimal cost factor (TXA: $11.40; Amicar: $10.56) This is a concern for surgical patients due to transfusion related complications, limited blood supply, and health care costs (Falana & Patel, 2014). Antifibrinolytic drugs are used to control blood loss and prevent transfusion related complications In one study, patients that received TXA had less blood loss compared to the patients that received Amicar (Boese, Centeno, & Walters, 2017).  The difference in blood loss was not considered significant Minimal cost factor TXA: $11.40 Amicar: $10.56

Background and Significance ~To Nursing and Shared Governance~ Post op hypotension for total hip and knee replacement patients: Delay in therapy Need for intervention  Medical management consults Increase length of stay Patients who experience less hypotension have better outcomes Nursing observation – less side effects when TXA was used

Project Overview Purpose Identify the antifibrinolytic that causes the least amount of hypotension and provides patients with the best outcomes

Project Overview Framework Evidenced Based Project Theoretical Model

Project Overview Setting: 28 bed Med-Surg unit at Midwest community hospital

Project Overview Methods: Data was retrospectively collected from total hip and knee joint patient charts from the time they arrived to PACU to 0400 to assess for hypotension 147 total hip & knee charts from 2018 78 received Amicar 69 received TXA Control group: 75 total hip & knee charts from 2012 No antifibrinolytic drug administered If hypotension was noted, patients were assessed for:  Delay in therapy Intervention Medical Management Consult

Project Description The CNS, CNO, and Shared Governance members provided support and feedback on the project. The CNS assisted in providing framework for evidenced based practice. Staff RNs were engaged through education on the use of antifibrinolytic drugs and the differences in incidence of hypotension between Amicar, TXA, and the control group. 

Project Results Baseline Data Control Group (n = 75) (No antifibrinolytic drug used) 1 patient experienced a delay in therapy 8 patients required intervention  1 patient had a medical management consult ordered *POD 0 = through NOC shift @ 0400. No blood pressures were considered for this study after 0400.   50.7% (n=38) patients had systolic BP below 100 31 males: 11 were hypotensive (28.9%) 44 females: 27 females were hypotensive (71.1%) 11 (28.9%) out of the 38 patients had BP below 90 ** some patients that were hypotensive had medical management consults ordered prior to the hypotension and were ordered for comorbidities such as diabetes, alcohol abuse, HTN, etc. 

Project Results Baseline Data Amicar (n=78) 5 patients experienced a delay in therapy 15 patients required intervention  4 patients required a medical management consult  *POD 0 = through NOC shift @ 0400. No blood pressures were considered for this study after 0400.   53.8% (n=42) patients experienced systolic blood pressure 100 total  32 males: 16 hypotensive (38.1%) 46 females: 26 hypotensive (61.9%)

Project Results Baseline Data TXA (n=69) 1 patient had a delay in therapy 3 patients required intervention 2 patients required a medical management consult  *POD 0 = through NOC shift @ 0400. No blood pressures were considered for this study after 0400. 9 patients were hypotensive (13%) 31 males: 2 hypotensive (22.2%) 38 females: 7 hypotensive (77.8%) Intervention: bolus administration, holding medications  Both patients that needed med management consults lost 800 and 900 ml of blood 

Project Results May 6, 2019: Presented the findings to the total joint meeting which included nurse practitioners, CRNA, clinical nurses, physical/occupational/respiratory therapists, nurse educators, CNS, and managers.   Orthopedic surgeons were not at the meeting, but a CRNA was present and relayed the data to the surgeons May 14, 2019: All orthopedic surgeons decided to use TXA for the total hip and knee replacement patients moving forward.

Project Results Post-Implementation Data TXA (n=13) – May 2019 Patient had a delay in therapy 0 patients had delay in therapy 0 patients required intervention 0 patients required a medical management consult  *POD 0 = through NOC shift @ 0400. No blood pressures were considered for this study after 0400.

Project Results The use of Amicar has been replaced by TXA for the total hip and knee replacement patients. Post-operative hypotension occurs about 40% less with the use of TXA as the primary antifibrinolytic drug used The post implementation data is comparable to the baseline data for TXA

Implications for Nursing Practice Nurses showed enthusiasm toward evidence-based change. Better patient outcomes: Early mobility with less incidence of syncopal episodes and less rapid responses Less delays in therapy  Decrease in discharge delays Majority of patients are going home on POD day 1 A potential barrier is drug availability due to natural disasters 

References Boese, C. K., Centeno, L., & Walters, R. W. (2017). Blood Conservation Using Tranexamic Acid Is Not Superior to Epsilon-Aminocaproic Acid After Total Knee Arthroplasty. THE JOURNAL OF BONE AND JOINT SURGERY, pp. 1621-1628. Dong, Q., Zhang, Y., Sun, X., & Hu, F. (2018). The effectiveness and safety of aminocaproic acid for reducing blood loss in T total knee and hip arthroplasty: A meta-analysis. International Journal of Surgery, pp. 156-163. Falana, O., & Patel, G. (2014). Efficacy and Safety of Tranexamic Acid Versus ε-Aminocaproic Acid in Cardiovascular Surgery. Annals of Pharmacotherapy, pp. 1563-1569. Ortman, E., Besser, M., & Klein, A. (2013). Antifibrinolytic agents in current anaesthetic practice. British Journal of Anaesthesia, pp. 549-563.

Contact Information Stephanie Marx, RN Aurora Medical Center Washington County, Hartford WI  262-670-7261 Mary Ann Petri, MSN, RN, CNS Aurora Medical Center Washington County, Hartford WI 262-670-7585

Thank You Douglas Bystrek, BSN, RN, Patient Care Manager Med-Surg @ Aurora Medical Center Washington County Carol Hein, MSN, RN, CMSRN,GCNS-BC, Nurse Residency Coordinator, Sr., Aurora Academy