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patients, such as treatment of perioperative anaemia or perioperative autologous blood salvage.10

Declaration of interest None declared. M. Mun˜oz 1,2* J. A. Pa´ramo1,2 1 Malaga, Spain 2 Pamplona, Spain * E-mail: [email protected]

doi:10.1093/bja/aeu078

Antifibrinolytics in subarachnoid haemorrhage Editor—Dr Ortmann and colleagues1 comprehensively review the evidence for antifibrinolytics across a spectrum of anaesthetic specialities. Concluding the section on subarachnoid haemorrhage (SAH), they state ‘there is a place for antifibrinolytic therapy as prophylaxis for early re-bleeding in

Declaration of interest None declared. S. R. Ford* G. Bird London, UK * E-mail: [email protected] 1 Ortmann E, Besser MW, Klein AA. Antifibrinolytic agents in current anaesthetic practice. Br J Anaesth 2013; 111: 549–63 2 Gaberel T, Magheru C, Emery E, et al. Antifibrinolytic therapy in the management of aneurysmal subarachnoid haemorrhage revisited. A meta-analysis. Acta Neurochir (Wien) 2012; 154: 1– 9 3 Baharoglu MI, Germans MR, Rinkel GJ, et al. Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2013; CD001245 4 Steiner T, Juvela S, Unterberg A, et al. European stroke organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis 2013; 35: 93 – 112 5 Dorhout Mees SM, Algra A, Peter Vandertop W, et al. Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomised placebo-controlled trial. Lancet 2012; 380: 44– 9 6 Roberts I, Shakur H, Ker K, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 2011; 377: 1096– 101

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1 Ortmann E, Besser MW, Klein AA. Antifibrinolytic agents in current anaesthetic practice. Br J Anaesth 2013; 111: 549– 63 2 Ker K, Prieto-Merino D, Roberts I. Systematic review, meta-analysis and meta-regression of the effect of tranexamic acid on surgical blood loss. Br J Surg 2013; 100: 1271– 9 3 European Medicines Agency. A.III. Wording to be included in the Summary of Products Characteristics and Package Leaflet of tranexamic acid medicinal products listed in Annex I (as adopted by the CHMP on 19 June 2012). Available from http://www.ema .europa.eu/docs/en_GB/document_library/Referrals_document/ Antifibrinolytic_medicines/WC500122923.pdf (accessed on 9 January 2013) 4 Okamura K, Nakagawa I, Hidaka S, Okada Y, Kubo T, Kato T. Perioperative changes of blood coagulability evaluated by thromboelastography (TEG) in patients undergoing total knee and total hip arthroplasty. Masui 2007; 56: 645– 9 5 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89: 780–5 6 Spahn DR. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology 2010; 113: 482–95 7 Mun˜oz Go´mez M, Pa´ramo Ferna´ndez JA. Intravenous administration of tranexamic acid to decrease bleeding and transfusion in knee and hip prosthetic surgery: is it safe and cost-effective? Med Clin (Barc) 2013; 141: 207– 9 8 Iturbe T, Cornudella R, de Miguel R, et al. Hypercoagulability state in hip and knee surgery: influence of ABO antigen system and allogenic transfusion. Transfus Sci 1999; 20: 17– 20 9 Zufferey PJ, Miquet M, Quenet S, et al. Tranexamic acid in hip fracture surgery: a randomized controlled trial. Br J Anaesth 2010; 104: 23–30 10 Leal SR, Mun˜oz M, Asuero M, et al. Spanish consensus statement on alternatives to allogeneic blood transfusion: the ‘Seville Document’ update 2013. Blood Transfus 2013; 17: 1– 25. doi: 10.2450/ 2013.0029-13

subarachnoid haemorrhage’. We contend that the situation is more controversial than Ortmann and colleagues suggest. Recent systematic reviews on antifibrinolytics in SAH are equivocal. A recent meta-analysis found evidence of improved functional outcome with short-term use (i.e. ,72 h postictus);2 but, the most recent Cochrane review found a reduction in re-bleeding was not accompanied by improved mortality or morbidity.3 Recent European guidelines reflect the equivocal evidence base, upholding the decade-old consensus that the benefit of antifibrinolytics in aneurysmal SAH is outweighed by the increased risk of delayed cerebral ischaemia.4 There have been false dawns in SAH management before—notably with supplementary magnesium, which ultimately ended with MASH-25—and enthusiasm for antifibrinolytics in major trauma has been tempered by post hoc analysis showing that administration more than 3 h post-injury is associated with excess mortality.6 This, combined with the increased risk of cerebral ischaemia3 and thromboembolism7 associated with antifibrinolytics in SAH, suggests that further research is needed to clarify their exact role in managing SAH patients, particularly with relation to timing. Furthermore, the definitive prevention of re-bleeding is aneurysmal coiling or clipping (with an aneurysmal re-bleeding rate under 1% at 6 yr post-intervention).8 Any benefit from antifibrinolytics in SAH is likely to be as a temporary measure until the offending aneurysm is secured. Quality improvement is better coming from greater availability of interventional radiology and prompt coiling than from a drug that is far from risk-free.

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7 Starke RM, Kim GH, Fernandez A, et al. Impact of a protocol for acute antifibrinolytic therapy on aneurysm rebleeding after subarachnoid haemorrhage. Stroke 2008; 39: 2617– 21 8 Molyneux AJ, Kerr RS, Birks J, et al. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term followup. Lancet Neurol 2009; 8: 427–33

doi:10.1093/bja/aeu079

Antifibrinolytics and current anaesthetic

Declaration of interest None declared.

Declaration of interest

M. H. Davies S. Jagannathan* Birmingham, UK * E-mail: [email protected]

1 Ortmann E, Besser MW, Klein AA. Antifibrinolytic agents in current anaesthetic practice. Br J Anaesth 2013; 111: 549–63 2 Cata JP, Gottumukkala V. Blood loss and massive transfusion in patients undergoing major oncological surgery: what do we know? ISRN Anaesthesiol 2012; Article ID 918938: 11.

doi:10.1093/bja/aeu080

Use of antifibrinolytics in liver transplantation Editor—We read with interest Dr Ortmann and colleagues’ review on the role of antifibrinolytics.1 With regard to liver

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None declared. V. McMullan* E. Thomson C. Beattie Edinburgh, UK * E-mail: [email protected] 1 Ortmann E, Besser MW, Klein AA. Antifibrinolytic agents in current anaesthetic practice. Br J Anaesth 2013; 111: 549–63 2 Roullet S, Pillot J, Freyburger G, et al. Rotation thromboelastometry detects thrombocytopenia and hypofibrinogenaemia during orthotopic liver transplantation. Br J Anaesth 2010; 104: 422–8 3 Gorlinger K. Coagulation management during liver transplantation. Hamostaseologie 2006; 26(Suppl. 1): 64 –76 4 Warnaar N, Mallett SV, Klinck JR, et al. Aprotinin and the risk of thrombotic complications after liver transplantation: a retrospective analysis of 1492 patients. Liver Transpl 2009; 15: 747– 53 5 Molenaar IQ, Warnaar N, Groen H, Tenvergert EM, Slooff MJ, Porte RJ. Efficacy and safety of antifibrinolytic drugs in liver transplantation: a

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Editor—We read with interest the article by Ortmann and colleagues.1 One aim of the highly informative and well-written review article was to enhance further discussion regarding the use of antifibrinolytic agents. One important area not mentioned in the article on the use of antifibrinolytic agents is the effective role these agents have in major oncological surgeries. During the resection of retroperitoneal sarcomas, for example, massive intra- and postoperative blood loss is not uncommon. Such patients often possess multiple risk factors for haemorrhage; these include tumour factors modulating the fibrinolytic process, the effects of chemotherapeutic agents, and the presence of anticoagulant drugs.2 These together with the complexity of surgical resection undertaken and vascularity of the tumour present a clinical scenario where antifibrinolytics can be effectively used. It is our view that antifibrinolytic agents are an important intervention not to be overlooked. Although antifibrinolytics have very little inherent prothrombotic property, we would be grateful if the authors could share their experience on the use of antifibrinolytics in patients who have an indwelling inferior venacaval filter.

transplantation, it was highlighted that more than threequarters of patients undergoing this procedure develop perioperative hyperfibrinolysis, and prophylactic antifibrinolytic agents should be considered.1 This quoted incidence of fibrinolysis was from a prospective observational study of 23 patients in Bordeaux based on a reduction in euglobulin lysis time (ELT) .50% in 18 patients (78.3%).2 Only two patients (8.7%) had a ROTEM demonstrating a typical hyperfibrinolysis trace. The use of antifibrinolytics in instances of bleeding was not emphasized. Perioperative bleeding in liver transplantation is often multifactorial. Point-of-care coagulation testing allows early detection of hyperfibrinolysis in the bleeding patient and informs clinicians about the individual patient’s requirement for antifibrinolytic drugs.3 These agents may increase the risks of vascular occlusion of the graft and other thrombotic events.4 While this was not demonstrated in a meta-analysis published in 2007, its limitations were numerous and the authors clearly state a large prospective randomized trial with thromboembolic events as the primary endpoint would be preferable to determine actual risk.5 In our unit, we have just completed a review of ROTEM data for 181 consecutive liver transplant procedures and, in a similar fashion to Roullet and colleagues in Bordeaux, assessed coagulation at five fixed time-points during surgery. Our data showed that 12 of 181 patients (6.7%) developed fibrinolysis during liver transplantation. All of these cases were treated successfully with tranexamic acid. We therefore suggest that routine administration of antifibrinolytics is not indicated, given its low incidence and success of treatment when identified. In view of the potential for thrombotic complications, we reserve the use of antifibrinolytic agents to those patients who are bleeding and have a ROTEM demonstrating a typical hyperfibrinolysis trace.

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