Research Priorities in Tranexamic Acid After Trauma: Secondary Analysis of the National Trauma Research Action Plan

INTRODUCTION

Tranexamic Acid (TXA) is an antifibrinolytic drug that is used in traumatic hemorrhage and TBI. Although TXA is considered relatively safe, inexpensive and is widely available, data regarding its mechanisms, optimal dosing, and timing, as well as relative risks and benefits for different patient populations, are inconsistent. In this study we aim to identify and summarize consensus research questions related to TXA across all NTRAP Delphi expert panels to identify priorities for future research on TXA in trauma.

METHODS

A secondary analysis was performed using consensus-based research priorities collected by 11 NTRAP topic panels using a Delphi methodology. The database of questions was queried for the keywords "tranexamic" and "TXA". The identified questions were sorted by subject matter and summarized.

RESULTS

7 panels included a total of 73 TXA-related questions. 46 questions reached consensus. The most addressed topic was outcomes (discussed in 64% of questions) followed by indications (49%) and specific patient populations (38%). Due to overlap across panels, questions were summarized and sorted by topic resulting in 21 priority research questions.

CONCLUSIONS

73 total questions and 46 questions reaching consensus were identified by NTRAP panelists. The key topics identified in these questions should be prioritized in future funded research on TXA in trauma.

LEVEL OF EVIDENCE

Original Research, IV.

Statistical Power of Randomized Controlled Trials in Trauma Surgery

BACKGROUND

Our purpose was to conduct a bibliometric study investigating the prevalence of underpowered randomized controlled trials (RCTs) in trauma surgery.

STUDY DESIGN

A medical librarian conducted a search of RCTs in trauma published from 2000 to 2021. Data extracted included study type, sample size calculation, and power analyses. Post hoc calculations were performed using a power of 80% and an alpha level of 0.05. A CONSORT checklist was then tabulated from each study as well as a fragility index for studies with statistical significance.

RESULTS

In total 187 RCTs from multiple continents and 60 journals were examined. A total of 133 (71%) were found to have "positive" findings consistent with their hypothesis. When evaluating their methods, 51.3% of articles did not report how they calculated their intended sample size. Of those that did, 25 (27%) did not meet their target enrollment. When examining post hoc power, 46%, 57%, and 65% were adequately powered to detect small, medium, and large effect sizes, respectively. Only 11% of RCTs had complete adherence with CONSORT reporting guidelines and the average CONSORT score was 19 out of 25. For positive superiority trials with binary outcomes, the fragility index median (interquartile range) was 2 (2 to 8).

CONCLUSIONS

A concerningly large proportion of recently published RCTs in trauma surgery do not report a priori sample size calculations, do not meet enrollment targets, and are not adequately powered to detect even large effect sizes. There exists opportunity for improvement of trauma surgery study design, conduct, and reporting.