Medical Directive Title:
Preoperative Written Order for Tranexamic Acid (TA) in Orthopedic Surgery
Lead Contact Person: Donna Berta, PBCP Coordinator
Program: Surgery / Anesthesia and Perioperative Medicine Approval By: Medical Advisory Committee
Original Effective Date:
Revised Date: Reviewed Date:
This Medical Directive Applies to: All LHSC sites or
LHSC-UH LHSC-VH LHSC-SSH
Order:
Knee surgery:
Send to Surgical Prep Unit Tranexamic acid * mg (wt ** kg), in 50 mL 0.9 % sodium chloride IV, administer at
patellar clamping v/o Dr. F. Ralley/_____ PBCP RN Hip surgery:
Send to Surgical Prep Unit
Tranexamic acid * mg (wt **kg), in 50 mL 0.9 % sodium chloride IV, administer 10 minutes prior to
skin incision
v/o Dr. F. Ralley/_____ PBCP RN
* dose of TA based on table Tranexamic Acid order per Patient Weight Increment (see Appendix 2)
** patient’s weight measured at Preadmission Clinic assessment or estimate if patient unable to weight
Appendix Attached? Yes No Recipient Patients:
University Hospital Orthopedic Surgery patients of Drs. Bourne, Howard, MacDonald, McAuley, McCalden, and Naudie assessed via Preadmission Clinic undergoing elective surgical procedures
• unicompartmental, primary, bilateral, revision knee joint replacement • primary, bilateral, revision hip joint replacement
• periacetabular and femoral osteotomy and open surgical dislocation hip surgery Authorized Implementers:
Position / Title Qualifications / Certifications Registered Nurse RN in the Blood Conservation
Program
Indications & Contraindications: Indications:
1. All University Hospital Orthopedic Surgery patients assessed via Preadmission Clinic undergoing elective surgical procedures (procedures as listed Recipient Patients) provided the patient has absolutely no history of previous thrombotic vascular event (TVE)
2. For University Hospital Orthopedic Surgery patients assessed via Preadmission Clinic undergoing elective orthopedic surgical procedures not listed in Recipient Patients, if the PBCP nurse believes TA might be indicated, she may contact the attending Orthopedic Surgeon for direction regarding potential implementation of intra-operative TA
Relative Contraindications:
1. The PBCP Nurse will consult the PBCP Director or their designate regarding patients with history of TVE. The PBCP Director or designate will review such patients to assess the patient specific risk/benefit profile and advise the PBCP nurse if TA is to be ordered or not.
2. The PBCP Nurse will consult the PBCP Director or their designate regarding patients with drug eluting stents to treat coronary artery disease within the previous 2 years and ongoing Plavix treatment. The PBCP Director or designate will review such patients to assess the patient specific risk/benefit profile and advise the PBCP nurse if TA is to be ordered or not.
• Absolute Contraindications:
1. Patients with history of TVE in previous 12 months or requiring life long anticoagulation related to previous TVE
Medication / Drug Table: Drug Name (GENERIC only) Route of Administration & Dosage Range Indication Absolute
Contraindications Considerations for Dosage adjustment (e.g. Renal or hepatic) Special Monitoring Requirements (i.e. lab tests) Tranexamic Acid Intravenous in 50 mL 0.9 % sodium chloride minibag See Appendix 2 regarding dosage range Administered intraoperatively by Attending Anesthesiologist To decrease surgical blood loss in orthopedic knee and hip joint surgery Patients with history of TVE in previous 12 months or requiring life long anticoagulation related to previous TVE
none none
Reference:
1. Compendium of Pharmaceuticals and Specialties. Canadian Pharmacists Association, Ottawa 2007:
Cyklokapron, 649.
2. LHSC intranet Parenteral Drug Administration Manual
http://www.lhsc.on.ca/priv/monograph/Of8olI6eAhQAABlCTNE.htm Consent:
• Attending Orthopedic Surgeon who obtains the surgical procedure consent, also obtains consent for blood and blood products and any alternatives (Form #8460- 5645 revised 2008)
Educational Requirements
Information or educational requirements to guide practice include:
• Minimum of 5 years recent clinical experience in surgical patient care • Completion of ONTraC blood conservation orientation program • Ongoing participation in ONTraC program continuing education
Appendix attached? Yes No Documentation & Communication:
• PBCP assessment, consultation with PBCP Director or their designate, plan of care and treatment implemented is documented on the patient’s Health Record utilizing Perioperative Blood Conservation Program form (NSR5080 revised 2009).
• Written order for TA is documented on the LHSC Patient Care Order form (8460- 5602 revised 2009)
Review and Quality Monitoring Guideline:
• For this Medical Directive TVE is defined as: stroke, transient ischemic attack, deep vein thrombosis, pulmonary embolism
• The PBCP director or their designate will be contacted via email (as per LHSC Electronic Mail Use Policy INT 006) regarding patients with history of TVE. The PBCP Director or designate will review such patients to assess the patient specific risk/benefit profile and will reply by email to advise the PBCP nurse if TA is to be ordered or not.
In situations of limited pre-operative time frame, telephone communication will occur • All University Hospital Orthopedic Surgeons track their own patient TVE incidents;
frequency of TVE incidents is reviewed semi-annually at Orthopedic Surgeons Division meeting. Dr. D. Naudie, Orthopedic Surgeon and PBCP Committee
member will advise PBCP Director or their designate of any increase in frequency of such incidents
• Blood transfusion rates for University Hospital Orthopedic Surgery procedures are reported semi annually to the PBCP Director and to Orthopedic Surgeons by Donna Berta, PBCP Coordinator
Professional Staff Approvals (Physician, Dentist, Midwife):
• Identify all Professional Staff members (<10 list by individual name, >10 list by title & program) responsible for patients who may receive an order or
procedure under this medical directive.
NAME DEPARTMENT / PROGRAM
Dr. Fiona Ralley Director, PBCP Dr. Ian Chin-Yee Hematologist, PBCP Dr. Cyrus Hsia Hematologist, PBCP
SRG-2010-003
Administrative Authorization Approval Form
Please note: signature pages are not to be signed until the medical directive has been approved.
Medical Directive: Preoperative Written Order for Tranexamic Acid (TA) in Orthopedic Surgery
Lead Contact Person (s): Donna Berta, PBCP Coordinator Administrative Authorizations
(approved by): Signature Date
Chair, LHSC Medical Advisory Committee / Dr. Christopher Fernandes
Chair, Drug & Therapeutics Committee / Dr. David Massel Director, Perioperative Blood Conservation Program / Dr. Fiona Ralley
Hematologist, Perioperative Blood Conservation Program / Dr. Ian Chin-Yee
City-Wide Chair-Chief Anesthesia & Perioperative Medicine / Dr. Davy Cheng Anesthesia Site Chief – University Hospital / Dr. Chris Harle
Orthopedic Surgery Division Chief / Dr. James Roth
Surgery Site Chief – University Hospital / Dr. Steven J.
MacDonald
Director, Surgical Care Program / Ms. Carol Rhiger
Nursing Professional Practice / Kathleen Ledoux, or delegate
Implemented by: (Person(s) performing
initiation or person representing a large group and
responsible for notification of that group)
Signature Date
Donna Berta, PBCP Coordinator Valerie Binns, PBC Coordinator