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Painter TW, McIlroy D, Myles PS, Leslie K. A survey of anaesthetists’ use of tranexamic acid in noncardiac surgery. Anaesth Intensive Care 2019; 47:76-84. [DOI: 10.1177/0310057x18811977] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Major bleeding in noncardiac surgery is common and associated with serious complications. The antifibrinolytic agent tranexamic acid (TXA) reduces bleeding and may reduce the risk of these complications. TXA also may have immunomodulatory effects that could reduce surgical site infection. Clinical trials of TXA in noncardiac surgery have been insufficiently powered to evaluate its efficacy and safety. Therefore, large randomised controlled trials of its use in noncardiac surgery are required. To ensure that future clinical trials are feasible and acceptable, we undertook a survey of Fellows of the Australian and New Zealand College of Anaesthetists (ANZCA). Our aims were to ascertain current patterns of TXA administration and to assess the acceptability of randomising patients to intravenous TXA or placebo. A 12-item survey was electronically mailed to 1001 ANZCA Fellows. Two hundred and eighty nine responses were received and analysed (response rate 29%). Ninety-eight percent of respondents had used intravenous TXA in noncardiac surgery; 67% give TXA routinely for lower limb arthroplasty, with smaller proportions giving TXA for spinal surgery (40%) and other major orthopaedic surgery (28%). Almost half (49%) give TXA routinely for major trauma surgery. Thirty-six percent indicated that they did not give TXA for major vascular, abdominal, pelvic or thoracic surgery. The majority administered TXA as a single, fixed dose. Fifty-seven percent agreed that there is uncertainty about the relative risks and benefits of perioperative TXA in noncardiac surgery and 87% agreed that large definitive trials determining the safety and efficacy of perioperative TXA in noncardiac surgery are required. These results indicate that for ANZCA Fellows the use of TXA in noncardiac surgery is highly variable, that there is uncertainty about the safety and efficacy of TXA, and that a large trial would be acceptable.
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Affiliation(s)
- Thomas W Painter
- Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, Australia
- Discipline of Acute Care Medicine, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - David McIlroy
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Australia
- Monash University, Melbourne, Australia
| | - Paul S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - Kate Leslie
- Royal Melbourne Hospital, Melbourne, Australia
- Centre for Integrated Critical Care Medicine, University of Melbourne, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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Painter TW, Daly DJ, Kluger R, Rutherford A, Ditoro A, Grant C, Howell S. Intravenous tranexamic acid and lower limb arthroplasty-a randomised controlled feasibility study. Anaesth Intensive Care 2018; 46:386-395. [PMID: 29966112 DOI: 10.1177/0310057x1804600407] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Tranexamic acid (TA) is widely reported to reduce bleeding and the risk of blood transfusion in patients undergoing lower limb arthroplasty. No study in this setting has had adequate power to examine for the effect of TA on either uncommon, but clinically important, adverse events or patient-centric endpoints. A large randomised controlled trial (RCT) is required to address these questions. As a preliminary feasibility study, we conducted an investigator-initiated, prospective, randomised, double blind placebo-controlled trial in 140 patients, aged 45 years or older, undergoing elective primary or revision hip or knee joint replacement. Subjects were randomised to receive intravenous (IV) TA or a placebo. The primary endpoints were the proportion of patients receiving allogenic blood transfusion and the feasibility of extending our trial methodology to a large trial of TA in this population. Secondary endpoints included a range of adverse clinical and surgical events as well as several patient-centric questionnaires. Red blood cell transfusion occurred in 15% of all patients prior to discharge from hospital. Transfusion rates were significantly different between the TA and placebo groups (8.5% versus 21.7%, <i>P</i>=0.03). Three out of four feasibility endpoints were met, with recruitment being slower than expected. No significant differences were seen between groups in the secondary endpoints. Despite a lower rate of transfusion than that widely reported, IV TA reduced transfusion in patients undergoing lower limb arthroplasty. Our trial methodology would be feasible in the setting of a large multicentre study to investigate whether TA is safe and reduces bleeding in lower limb arthroplasty.
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Affiliation(s)
- T W Painter
- Clinical Senior Lecturer, Discipline of Acute Care Medicine, Adelaide Medical School, University of Adelaide; Adelaide, South Australia
| | - D J Daly
- Staff Anaesthetist, Department of Anaesthesia and Perioperative Medicine, Alfred Hospital; Clinical Senior Lecturer, Monash University; Melbourne, Victoria
| | - R Kluger
- Senior Staff Anaesthetist, Department of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital, Melbourne, Victoria
| | - A Rutherford
- Research nurse, Pain and Anaesthesia Research Centre, Discipline of Acute Care Medicine, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia
| | - A Ditoro
- Research Nurse, Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Alfred Hospital, Victoria
| | - C Grant
- Research Associate, Discipline of Acute Care Medicine, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia
| | - S Howell
- Senior Statistician, Data Design and Statistics Service, Adelaide Health Technology Assessment, School of Public Health, The University of Adelaide, Adelaide, South Australia
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