Objective: To review the efficacy and safety of a single dose of intravenous tranexamic acid (TXA) given preoperatively. Summary Background Data: TXA is a synthetic antifibrinolytic that has been used in various surgical disciplines to reduce blood loss, blood transfusions, ecchymosis, and hematoma formation. However, there is no universal standard on the most effective dose and route of TXA administration, limiting its routine use in many centers. This study evaluates the current evidence for the efficacy and safety of a single preoperative dose of TXA on surgical blood loss in all surgical disciplines. Methods: With the guidance of a research librarian, in accordance with the Cochrane Handbook Medline, Cochrane Central and Embase were searched in November 2018. Search terms included “Tranexamic Acid” AND “Intravenous,” with studies limited to randomized controlled trails in adult humans. Two independent reviewers and an arbitrator assessed articles for inclusion. Criteria included a single preoperative bolus dose of intravenous TXA, surgical patients, and intraoperative blood loss measurement or perioperative blood loss up to 24 hours postsurgery. Quality assessment was done using the Cochrane Collaboration risk-of-bias tool by 2 reviewers. Statistical analysis was carried out using Cochrane Review Manager 5.3. The primary outcome was surgical blood loss. Secondary outcomes included venous thromboembolic complications, transfusion requirements, and dosing. Results: A total of 1906 articles were screened, 57 met inclusion criteria. The majority of included studies were orthopedic (27), followed by obstetric and gynecological (16), oral maxillofacial and otolaryngology (10), cardiac (3), and 1 plastic surgery study focusing on acute burn reconstruction. Across all surgical specialties (n = 5698), the perioperative estimated blood loss was lower in patients receiving TXA, with a standard mean difference of −153.33 mL (95% CI = −187.79 to −118.87). Overall, surgical patients with TXA had a 72% reduced odds of transfusion (odds ratio = 0.28 [95% CI = 0.22–0.36]). The most frequently used dose of TXA was 15 mg/kg. There was no difference in the incidence of venous thromboembolic events between TXA and control groups. Conclusions: While there is a growing body of evidence to support benefits of perioperative TXA use, this is the first meta-analysis to identify the efficacy and safety of a single preoperative dose of IV TXA. The potential implications for expanding the use of preoperative TXA for elective day surgery procedures is substantial. Preoperative intravenous TXA reduced perioperative blood loss and transfusion requirements in a variety of surgical disciplines without increasing the risk of thromboembolic events. Therefore, it should be considered for prophylactic use in surgery to reduce operative bleeding.
Several complex decisions face women considering breast reconstruction, such as whether or not to undergo reconstruction, type of reconstruction, and timing of reconstruction (immediate versus delayed). Unlike many other aspects of breast cancer therapy, the patient's preferences play a central role in reconstructive decisions. Although choice may offer a woman a sense of control at a time when such opportunities may feel scarce, the decisions can be challenging to make. [1][2][3] Background: Decision aids are useful adjuncts to clinical consultations for women considering breast reconstruction. This study compared the impact of two online decision aids, the Breast RECONstruction Decision Aid (BRECONDA) and the Alberta Health Services (AHS) decision aid, on decisional conflict, decisional satisfaction, and decisional regret. Methods: This randomized controlled trial included 60 women considering whether or not to undergo breast reconstruction. Two online decision aids, the AHS and the BRECONDA, were compared using randomized two-arm equal allocation. Participants responded to questionnaires at baseline, after the first and second consultations, and at 6 weeks and 6 months after deciding to, or not to, undergo reconstruction. Change in decisional conflict scores was compared between the BRECONDA and the AHS decision aid. Secondary outcomes included decisional regret and decisional satisfaction. Results: Both groups were similar in demographic, clinical, and behavioral characteristics. Women spent more time consulting the BRECONDA in comparison to women using the AHS decision aid (56.7 ± 53.8 minutes versus 28.4 ± 27.2 minutes; P < 0.05). Decisional conflict decreased (P < 0.05), and decisional satisfaction improved over time in both groups (P < 0.05). However, there were no differences based on the type of decision aid used (P > 0.05). Both decision aids had a similar reduction in decisional regret (P > 0.05). Conclusions: Decision aids decrease decisional conflict and improve decisional satisfaction among women considering breast reconstruction. Physicians should therefore offer patients access to decision aids as an adjunct to breast reconstruction consultations to help patients make an informed decision. (Plast.
Background: The objective of this study was to compare the costs of performing metacarpal fracture fixation in minor surgery (MS) versus the main operating room (OR) at a tertiary care center in Calgary, Alberta, from the institutional perspective. Methods: Data were extracted from the Operating Room Information System and the Business Advisory System by a financial analyst. All data were based on actual expenses from the 2016–2017 fiscal year (US$). Direct costs included: staffing, supply, day (outpatient) surgery unit, post-anesthesia care unit (PACU), and anesthesia (anesthesiologist and equipment) costs. Surgeon and hardware costs were deemed neutral and excluded from the analysis. Results: The total cost of metacarpal fixation in MS was $250, compared to $2,226 in the OR, after surgeon and hardware costs were excluded. Staffing costs are a major contributing factor to cost by location ($75 in MS versus $233 in OR), largely attributable to 0.5 nursing staff per room in MS compared to 3 nursing staff per room in the OR. Supply costs (minor tray, $94 versus case cart, $247) are also greater for OR cases. The combined costs for DSU ($465), PACU ($435), and anesthesia ($247) totaled $1,147 and are only incurred for OR cases. Conclusions: Repair of metacarpal fractures in MS represents a substantial cost-minimization strategy from the institutional perspective. Staffing and supply costs by location and the additional combined costs of DS, PACU, and anesthesia are all contributing factors.
Pregnancy and parental leave among plastic surgery residents in Canada: a nationwide survey of attitudes and experiences O n average, following the completion of a surgical residency, exiting trainees in Canada are 33.2 years of age. 1 The average age at which mothers in Canada had their first child was 29.2 years in 2016. 2 Therefore, residents who hope to start a family may consider pregnancy dur ing their training. However, surgical residents are in an undesirable position to start a family because of their long work hours, the physically demanding nature of their work, specific occupational hazards and less flexibility in resi dency rotation scheduling. 3 A survey of members and candidates of the Amer ican Society of Plastic Surgeons found that 72.6% of women and 39.2% of men delayed having children because of the demands of training. 4 As there is an increased risk of both maternal and fetal complications related to deferred childbirth, especially after age 35, many plastic surgery graduates may find themselves conflicted between the demands of a professional career and par enting priorities. 5 With only 26 new trainees starting plastic surgery residencies each year in Canada, it can be challenging for small surgical programs like plastic surgery to accommodate parental leave. Starting a family during residency can be compli cated and situationally dependent, and it is important to understand the impact of the environment on this life event by investigating the experiences of resi dents and recent graduates across Canada. This study aimed to report the experiences, attitudes and perceived support of Canadian plastic surgery resi dents and surgeons with respect to pregnancy and parenting during training.
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