1. 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

2. 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

3. 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

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

5. Project Overview
Framework
Evidenced Based Project
Theoretical
Model

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

7. 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

8. 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. 

9. 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 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. 

10. 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 No blood pressures were considered for this study after  
53.8% (n=42) patients experienced systolic blood pressure 100 total 
32 males: 16 hypotensive (38.1%)
46 females: 26 hypotensive (61.9%)

11. 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 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 

12. 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.

13. 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 No blood pressures were considered for this study after 0400.

14. 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

15. 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 

16. 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 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 Falana, O., & Patel, G. (2014). Efficacy and Safety of Tranexamic Acid Versus ε-Aminocaproic Acid in Cardiovascular Surgery. Annals of Pharmacotherapy, pp Ortman, E., Besser, M., & Klein, A. (2013). Antifibrinolytic agents in current anaesthetic practice. British Journal of Anaesthesia, pp

17. Contact Information
Stephanie Marx, RN
Aurora Medical Center Washington County, Hartford WI 
Mary Ann Petri, MSN, RN, CNS
Aurora Medical Center Washington County, Hartford WI

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