Futility of end-of-life and emergency surgery in extreme high-risk patients: anaesthetists’ versus surgeons’ perspective
Futilidade da cirurgia ao fim da vida e de emergência em pacientes de extremo alto risco: perspectiva de anestesistas versus cirurgiões
The purpose of this study was to determine whether Tranexamic Acid (TXA) can significantly reduce perioperative blood loss in Total Shoulder Arthroplasty (TSA) performed under regional anesthesia.
We performed a randomized, single blinded, controlled study. Forty-five patients were submitted to TSA under regional anesthesia to treat cuff tear arthropathy, proximal humeral fractures, chronic instability, primary osteoarthrosis, and failures of previous prosthesis. Patients were randomized to either group TXA therapy (TXA), with 1 g intravenous (IV), or no Intervention (NTXA). Postoperative total drain output, hemoglobin variation, total blood loss, hemoglobin loss, and need for transfusion were measured. Pain-related variables were also assessed: postoperative pain assessment by visual analog scale, inpatient pain breakthrough, quality of recovery, length of stay, and coagulation function testing.
Participants presented a mean age of 76 years, 15.6% were male, 82.2% were American Society of Anesthesiologists (ASA) physical status I or II. There were no differences between groups concerning transfusions, operative time, Post-Anesthesia Care Unit (PACU) length of stay and in-hospital stay, and QoR-15 or postoperative pain. Bleeding measured by drain output at 2, 24 and 48 hours was significantly less in the TXA group at each timepoint. There was a difference in Hb variation – TXA: median (IQR) -1.4 (1.3) g.dL-1 vs. NTXA: -2.2 (1.3) g.dL-1; median difference: 0.80 (0.00–1.20); p = 0.047. aPTT was lower in TXA administered patients – TXA: median (IQR) 29.6 (14.0)s vs. NTXA: 33 (5.8)s; difference in medians: -4.00 (-6.50–-1.00); p = 0.012.
TXA use significantly decreased blood loss measured by drain output and Hb drop in TSA under regional anesthesia.
 M Prin, J Guglielminotti, O Mtalimanja, G Li, A. Charles Emergency-to-elective surgery ratio: a global indicator of access to surgical care World J Surg, 42 (2018), pp. 1971-1980
 AS Chiu, RA Jean, B Resio, KY. Pei Early postoperative death in extreme-risk patients: A perspective on surgical futility Surgery, 166 (2019), pp. 380-385
 AC Kwok, ME Semel, SR Lipsitz, et al. The intensity and variation of surgical care at the end of life: a retrospective cohort study Lancet, 378 (2011), pp. 1408-1413
 LL Maerz, AC Mosenthal, RS Miller, BA Cotton, OC. Kirton Futility and the acute care surgeon J Trauma Acute Care Surg, 78 (2015), pp. 1216-1219
 RS Morris, JM Ruck, AM Conca-Cheng, TJ Smith, TW Carver, FM. Johnston Shared decision-making in acute surgical illness: the surgeon's perspective J Am Coll Surg, 226 (2018), pp. 784-795