British journal of anaesthesia
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Tranexamic acid reduces surgical bleeding. Consistent with previous research, the POISE-3 (Peri-Operative Ischemic Evaluation-3) trial found that tranexamic acid reduces major bleeding by 25% and with a low probability of any increase in thromboembolic events. Wider tranexamic acid use will improve surgical safety, avoid unnecessary blood use, reduce the risk of transfusion transmitted infections, and save healthcare funds. 'Consideration of tranexamic acid use' should be included in the safe surgery checklist. We have the evidence, and we need to act on it.
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Tobacco smoking is a leading preventable cause of death and increases perioperative risk. Determinants of smoking abstinence after noncardiac surgery and the association between smoking and 1-yr vascular outcomes are not fully elucidated. ⋯ Long-term tobacco abstinence is more likely after major surgery in those with serious medical comorbidities. Interventions to prevent smoking resumption after surgery remain a priority. Clinical trial registration NCT00512109.
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Editorial Comment Multicenter Study
Translating evidence into practice: still a way to go.
Chiu and colleagues report a retrospective analysis describing the 5-yr trend in both intraoperative fluid and vasopressor administration in 32 250 patients undergoing elective abdominal surgery within the Multicenter Perioperative Outcomes Group (MPOG) database from 2015 to 2019, and exploring the association between these two factors and acute kidney injury. Modelling predicted the lowest risk for acute kidney injury when the administered crystalloid volume was 15-20 ml kg-1 h-1, and an 80% increase in risk for acute kidney injury as intraoperative vasopressor use increased from 0 to 0.04 μg kg-1 min-1 of norepinephrine equivalents. Although these results are consistent with those of a large, randomised trial (REstrictive Versus LIbEral Fluid Therapy in Major Abdominal Surgery [RELIEF]) published in 2018, the mean intraoperative volume of crystalloid administered in the current study declined monotonically through every year included, from 6.4 ml kg-1 h-1 in 2015 to 5.5 ml kg-1 h-1 in 2019. These new findings support the broad generalisability of the RELIEF trial; highlight the complexity of the relationship between intravenous crystalloid volume infused, arterial pressure, and acute kidney injury; and demonstrate the ongoing challenge of translating high-quality evidence into clinical practice.