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Original Article
Peri-operative administration of tranexamic acid in lower
limb arthroplasty: a multicentre, prospective cohort study
T. D. Lloyd,
1,2
G. Neal-Smith,
2
J. Fennelly,
2
H. Claireaux,
3
C. Bretherton,
2,4
A. J. Carr,
5
M. Murphy,
6,7
B. J. Kendrick,
8
A. J. R. Palmer,
9
and collaborators
a
1 National Institute for Health Research (NIHR) Academic Clinical Research Fellow, 4 Clinical Research Fellow, 5
Professor, 8 Honorary Senior Lecturer and Consultant, 9 NIHR Clinical Academic Lecturer, Nuffield Department of
Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
2 Trainee, 3 British Army General Duties Medical Officer, Oxford Surgical Collaborative for Audit and Research, Oxford,
UK
6 Professor, University of Oxford, Oxford, UK, 7 Consultant, NHS Blood and Transplant, Oxford, UK
Summary
In the UK, tranexamic acid is recommended for all surgical procedures where expected blood loss exceeds
500 ml. However, the optimal dose, route and timing of administration are not known. This study aimed to
evaluate current practice of peri-operative tranexamic acid administration. Patients undergoing primary total hip
arthroplasty, total knee arthroplasty or unicompartmental knee arthroplasty during a 2-week period were eligible
for inclusion in this prospective study. The primary outcome was the proportion of patients receiving tranexamic
acid in the peri-operative period. Secondary outcomes included: dose, route and timing of tranexamic acid
administration; prevalence of pre- and postoperative anaemia; estimated blood loss; and red blood cell
transfusion rates. In total, we recruited 1701 patients from 56 NHS hospitals. Out of these, 1523 (89.5%) patients
received tranexamic acid and of those, 1052 (69.1%) received a single dose of 1000 mg intravenously either pre-
or intra-operatively. Out of the 1701 patients, 571 (33.6%) and 1386 (81.5%) patients were anaemic (haemoglobin
<130 g.l
1
) in the pre- and postoperative period, respectively. Mean (SD) estimated blood loss for all included
patients was 792 (453) ml and 54 patients (3.1%) received a red blood cell transfusion postoperatively. The
transfusion rate for patients with pre-operative anaemia was 6.5%, compared with 1.5% in patients without
anaemia. Current standard of care in the UK is to administer 1000 mg of tranexamic intravenously either pre- or
intra-operatively. Approximately one-third of patients present for surgery with anaemia, although the overall red
blood cell transfusion rate is low. These data provide useful comparators when assessing the efficacy of
tranexamicacid and other patient blood managementinterventions in future studies.
.................................................................................................................................................................
Correspondence to: A. J. R. Palmer
Email: antony.palmer@ndorms.ox.ac.uk
Accepted: 12 March 2020
Keywords: anaemia; arthroplasty; blood loss; tranexamic acid; transfusion
a
For collaborators, see Appendix 1.
Twitter: @tomlloyd91; @GregNealSmith1; @harryclax; @BrethertonC; @MurphyProf; @AJRPalmer
Introduction
Primary hip and knee arthroplasty is often associated with
blood loss of more than a litre peri-operatively [1]. A
significant proportion of patients may require an allogeneic
red blood cell transfusion, with rates ranging from 0 to 47%
[2]. In addition, both postoperative anaemia and red blood
cell transfusion are associated with increased risks of
cardiopulmonary morbidity, surgical site infection and
©2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Associat ion of Anaesthetists 1
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
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Anaesthesia 2020 doi:10.1111/anae.15056
mortality [3, 4]. Therefore, strategies to minimise intra-
operative blood loss and promote blood conservation are a
priority for improving patient outcomes [5].
Tranexamic acid is a synthetic lysine analogue that
inhibits plasminogen activation and promotes clot
stabilisation. In patients undergoing total hip or knee
arthroplasty, tranexamic acid has been shown to reduce
peri-operative blood loss and red blood cell transfusion
rates [6]. The National Institute for Health and Care
Excellence (NICE) guidelines recommend tranexamic acid
is administered to all patients undergoing a surgical
procedure with estimated blood loss greater than 500 ml
[7]. However, the guidelines did not provide a
recommendation on the dose, route or timing of
tranexamic administration due to the heterogeneity of
studies to date. In order to design an optimal clinical trial
an improved understanding of current practice is required,
particularly in terms of clinically relevant comparator
interventions and outcome measures.
The primary aim of this study was to evaluate current
practice of peri-operative tranexamic acid administration in
patients undergoing primary hip and knee arthroplasty in
the UK. Secondary aims were to identify the prevalence of
pre- and postoperative anaemia and to determine
estimated blood loss and postoperative red blood cell
transfusion rates.
Methods
This study is reported according to STROBE guidelines. A
multicentre, prospective, observational study was
conducted between 3 September 2018 and 17 September
2018. Collaborators from NHS Trusts within the UK were
recruited via the National Orthopaedic Trainee
Collaborative network and the British Orthopaedic
Trainees Association. Each collaborator registered the
audit locally with a clinical lead and the clinical audit and
effectiveness department at their respective institution.
Research Ethics Committee approval was not required as
per the Health Research Authority assessment tool.
Collaborators completed and returned locked Excel
spreadsheets (Microsoft Corp, NM, USA). No direct or
indirect patient identifiable data were collected.
Patients undergoing elective primary total hip
arthroplasty, total knee arthroplasty or unicompartmental
knee arthroplasty within the study period were eligible for
inclusion. The following data were collected on tranexamic
administration: dose (mg); timing (pre-operative, intra-
operative, or postoperative); and route (oral, intravenous,
topical, intramuscular or combined). Additional data
included: body mass index ; weight; pre- and postoperative
haemoglobin concentration (Hb) and haematocrit (Hct);
and postoperative red blood cell transfusion requirements.
We calculated the estimated peri-operative blood loss for
each patient using the Gross equation (Equation 1). To
inform the estimated blood loss calculation, pre-operative
estimated blood volume was calculated using the
Lemmens-Bernstein-Brodsky equation [8].
Estimated blood loss ¼
estimated blood volume initial Hct final Hct
mean Hct
ð1Þ
Patients who were transfused intra-operatively or
received an autologous red blood cell transfusion before
the first postoperative full blood count were not included in
calculations of estimated blood loss.
Pre-operative tranexamic acid administration included
doses given between admission and surgical incision.
Intra-operative administration included doses given
between surgical incision until the recorded end of the
procedure. Postoperative administration included doses
given from the recorded end of the procedure until patient
discharge. Pre-operative Hb and Hct values were recorded
from the most recent pre-operative laboratory full blood
count. Postoperative Hb and Hct values were recorded
from the first laboratory full blood measured
postoperatively (and before any red blood cell blood
transfusion). Anaemia was defined as a haemoglobin
concentration less than 130 g.l
1
[9].
Regional variation in practice was explored by country
(England, Wales, Scotland, Northern Ireland), and England
was subdivided into Public Health England regions
(London, South East, South West, East of England, West
Midlands, East Midlands, North West, North East, and
Yorkshire and Humber).
We did not calculate a sample size for this analysis.
Differences between groups were assessed using an
unpaired, two-sided t-test for continuous variables and
Fisher’s exact test for categorical variables. All data
analyses were undertaken using STATA v14.2 (StataCorp,
TX, USA).
Results
Over the study period, data from 1714 patients
undergoing primary hip or knee arthroplasty were
included from 56 NHS hospitals in the UK (Fig. 1).
Thirteen patients were not included due to incomplete
data. Three were not included in the blood loss
calculations due to intra-operative transfusion (n =2) and
autologous transfusion (n =1) (Fig. 2).
2©2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists
Anaesthesia 2020 Lloyd et al. | Peri-operative tranexamic acid in orthopaedic surgery
Out of the 1701 patients included in the final analysis,
797 (46.9%) underwent total hip arthroplasty, 830 (48.9%)
total knee arthroplasty and 74 (4.4%) unicompartmental
knee arthroplasty. Mean (SD) weight of included patients
was 82.7 (18.3) kg and mean (SD) BMI was 30.2 (5.7) kg.m
2
.
In this study, 1523 out of 1701 (89.5%) received tranexamic
acid peri-operatively, with a similar proportion across all
three operations (Table 1). Mean (SD) estimated blood loss
for patients receiving tranexamic acid was 880.8 (458.6) ml
compared with 782.2 (450.8) ml for patients who did not
receive tranexamic acid (p =0.007).
The most commonly used tranexamic acid dosing
regimen was a single dose of 1000 mg administered
intravenously either pre-operatively [n =547 (36%)] or
intra-operatively [n =505 (33%)] (Fig. 3). Other routes
and timing of administration are displayed in Tables 1
Figure 1 Map of participating centres
Figure 2 Flow diagram of recruitment and analysis
©2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Associat ion of Anaesthetists 3
Lloyd et al. | Peri-operative tranexamic acid in orthopaedic surgery Anaesthesia 2020
and 2. A total of 1231 (72%) patients received a single
dose of tranexamic acid compared with 292 (17%) who
received multiple doses (Table 2). The most frequently
administered single dose was 1000 mg [n =1310
(86.1%)] (Fig. 3). Mean (SD) total cumulative dose
administered was 1112 (600.5) mg.
In total, 517 out of 1701 (33.6%) patients presented
with pre-operative anaemia and 1386 (81.5%) were anaemic
postoperatively (Table 3). Data on estimated blood loss and
transfusion rates for the overall cohort and according to
operation type are in Table 3. The number of patients with
an estimated blood loss of greater than 500 ml was 1252
(73.7%). Out of these, 1110 (88.7%) received tranexamic
acid. The transfusion rate for patients with pre-operative
anaemia was 37/571 (6.5%) compared with 17/1130 (1.5%)
in patients without anaemia (p <0.0001). Two patients
required intra-operative transfusions and both were
anaemic pre-operatively (Hb 109 g.l
1
and 107 g.l
1
).
There was regional variation in practice with the lowest
recorded rate of pre-operative anaemia in north-east
England (22.0%) and highest in the Yorkshire and Humber
Table 1 Routes of tranexamic acid administration in all patients and those undergoing total hip arthroplasty, total knee
arthroplasty and unicompartmental knee arthroplasty. Values are number (proportion).
Dose Route
All
n=1701
Total hip
arthroplasty
n=797
Total knee
arthroplasty
n=830
Unicompartmental
knee arthroplasty
n=74
No tranexamic acid 178 (10.4%) 77 (9.6%) 92 (11.1%) 9 (12.2%)
Single dose i.v. 1227 (72.1%) 614 (77.0%) 565 (68.1%) 48 (64.9%)
p.o. 1 (0.1%) 0 0 1 (1.4%)
i.m. 3 (0.2%) 0 3 (0.4%) 0
Multiple doses i.v. +i.v. 226 (13.3%) 86 (10.8%) 126 (15.2%) 14 (18.9%)
p.o. +p.o. 2 (0.1%) 1 (0.1%) 1 (0.1%) 0
i.v. +top 30 (1.8%) 14 (1.8%) 14 (1.7%) 2 (2.7%)
i.v. +i.m. 3 (0.2%) 0 3 (0.4%) 0
i.v. +p.o. 31 (1.8%) 5 (0.6%) 26 (3.1%) 0
i.v., intravenous; p.o., oral; i.m., intramuscular; top, topical.
Table 2 Timing of tranexamic acid administration in all patients and those undergoing total hip, knee or unicompartmental
knee arthroplasty. Values are number (proportion).
Dose Peri-operative timing
All
n=1701
Total hip
arthroplasty
n=797
Total knee
arthroplasty
n=830
Unicompartmental
knee arthroplasty
n=74
No tranexamic acid 178 (10.4%) 77 (9.6%) 92 (11.1%) 9 (12.2%)
Single dose Pre-operative 616 (36.3%) 369 (46.3%) 228 (27.5%) 19 (25.7%)
Intra-operative 593 (34.9%) 242 (30.4%) 322 (38.7%) 29 (39.2%)
Postoperative 22 (1.3%) 3 (0.4%) 18 (2.2%) 1 (1.4%)
Multiple doses Pre-operative 1 (0.1%) 0 1 (0.1%) 0
Intra-operative 70 (4.1%) 25 (3.1%) 42 (5.1%) 3 (4.1%)
Postoperative 2 (0.1%) 1 (0.1%) 1 (0.1%) 0
Pre-operative and intra-operative 117 (6.8%) 44 (5.4%) 65 (7.8%) 8 (10.8%)
Pre-operative and postoperative 57(3.4%) 19 (2.4%) 35 (4.2%) 3 (4.1%)
Intra-operative and postoperative 45 (2.7%) 17 (2.1%) 26 (3.1%) 2 (2.7%)
Figure 3 Histogram of single doses of tranexamic acid
(n =1231)
4©2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists
Anaesthesia 2020 Lloyd et al. | Peri-operative tranexamic acid in orthopaedic surgery
region (49.5%) (Fig. 4, Table S1). The rate of blood
transfusion was lowest in Northern Ireland (0%) and highest
in the Yorkshire and Humber region (7.6%) (Fig. 5, Table S2).
Discussion
Tranexamic acid was administered in approximately 90% of
patients undergoing primary hip or knee arthroplasty. The
Table 3 Anaemia prevalence, estimated blood loss and red blood cell transfusion rates in all patients and those undergoing
total hip arthroplasty, total knee arthroplasty and unicompartmental knee arthroplasty. Values are number (proportion) or mean
(SD).
All
n=1701
Total hip
arthroplasty
n=797
Total knee arthroplasty
n=830
Unicompartmental
knee arthroplasty
n=74
Proportion anaemic Hb <130 g.l
1
571 (33.6%) 290 (36.4%) 266 (32.0%) 15(20.3%)
Pre-operative haemoglobin; g.l
1
135.0 (13.5) 134.3 (13.7) 135.5 (13.3) 139 (12.1)
Postoperative haemoglobin; g.l
1
115.0 (15.3) 112.4 (15.4) 116.7 (14.8) 127 (11.3)
Estimated blood loss; ml 791.9 (452.5) 862.5 (473.3) 745.1 (423.5) 468.5 (324.8)
Red blood cell transfusion rate 54 (3.1%) 38 (4.7%) 13(1.6%) 3 (4.1%)
Esri, HERE, Garmin , (c) OpenStreetMap contri butors, and the GIS user
community
Rate (%) of
pre-op erative an aemia
22.0 - 25.0
25.1 - 30.0
30.1 - 35.0
35.1 - 40.0
40.1 - 45.0
45.1 - 50.0
Figure 4 Pre-operative anaemia prevalence by geographical region
©2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Associat ion of Anaesthetists 5
Lloyd et al. | Peri-operative tranexamic acid in orthopaedic surgery Anaesthesia 2020
most frequently adopted dosing regimen was 1000 mg
delivered intravenously as a single dose either pre-
operatively or intra-operatively. Approximately one-third of
patients presented for surgery with pre-operative anaemia.
Mean estimated blood loss exceeded 500 ml for primary
total hip and knee arthroplasty in over 70% of patients. The
postoperative red blood transfusion rate for our study
cohort was 3.1%.
The results of this study demonstrate good
compliance with current NICE standards (90% of
patients administered tranexamic acid) [7]. This rate of
compliance is significantly higher than reported in the
2016 National Comparative Audit of 471 patients
undergoing primary total hip arthroplasty and 289
undergoing primary total knee arthroplasty. In this audit,
63% of patients undergoing primary total hip
arthroplasty and 51% for primary total knee arthroplasty
received tranexamic acid [10].
There was variation in the dose, route and timing of
administration, reflecting the absence of a consensus
opinion on optimal tranexamic acid dosing regimens. A
large number of randomised controlled trials have been
performed comparing different routes, doses and timing of
administration, but the heterogeneity of these studies
makes interpretation difficult in terms of determining an
optimal dose [11]. To achieve clarity, future trials examining
dosing regimens should be performed against a common
comparator that is representative of current practice. We
have demonstrated that 1000 mg of tranexamic acid given
intravenously as a single dose, either pre-operatively or
intra-operatively, would be appropriate whilst also
maintaining acceptability to clinicians.
Esri, HERE, Garmin, (c) OpenStreetMap c ontributors, and the GIS user
community
Rate (%) of allogeneic
red cell transfusion
0.8 - 2.0
2.1 - 4.0
4.1 - 6.0
6.1 - 8.0
Figure 5 Incidence of allogeneic transfusion by geographical region
6©2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists
Anaesthesia 2020 Lloyd et al. | Peri-operative tranexamic acid in orthopaedic surgery
Previous studies show a reduction in blood loss and
allogeneic transfusion rates following combined topical and
intra-articular tranexamic acid compared with intravenous
alone and warrants consideration for routine clinical
practice [12]. Topical administration also overcomes
potential systemic toxicity in patients with renal failure.
Topical application was used in fewer than 2% of patients in
this cohort and always in combination with intravenous
tranexamic acid. Oral tranexamic acid administration may
offer equivalent effectiveness to intravenous and topical
administration but AT a much lower cost [13]. A concern
from in-vitro studies is potential toxicity to peri-
articular tissues when administered topically, which is
especially salient in unicompartmental knee arthroplasty
and further research is indicated to address this uncertainty
[14].
Cumulative doses of tranexamic acid ranged from 500
to 5000 mg given over 1–3 doses in this study. There is
inconsistent evidence of reduced blood loss with greater
doses of tranexamic acid and concerns over potential
toxicity with very high doses [15]. This study found the
majority of patients received a 1000 mg dose of
tranexamic acid rather than dosing based on patient
weight. To optimise the effectiveness of tranexamic acid,
optimal blood concentrations should be achieved early
and maintained. A 1000-mg bolus of tranexamic acid
maintains the minimal target concentration for 1.5 h after
administration [16]. While this may be effective at
addressing intra-operative blood losses, it is unlikely to
account for hidden blood losses postoperatively, which is
an important consideration in effective patient blood
management [17]. Studies have not demonstrated a
benefit from multiple doses of tranexamic acid for primary
arthroplasty [6] but may play a role in revision arthroplasty
surgery with longer surgical times and greater blood loss.
Tranexamic acid was most frequently administered intra-
operatively for total knee arthroplasty and pre-operatively
for total hip arthroplasty, perhaps because tranexamic acid
is usually administered when the tourniquet is released. An
ongoing Cochrane network meta-analysis may offer further
guidance regarding tranexamic acid administration in total
hip arthroplasty and total knee arthroplasty [11].
Approximately one-third of patients in our cohort were
anaemic pre-operatively, consistent with studies from other
countries [18]. This incidence is lower than the 2016
National Comparative Audit of 726 patients, which found
50% patients were anaemic before primary total hip
arthroplasty and 60% before primary total knee arthroplasty
(Hb <130 g.l
1
men and Hb <120 g.l
1
women). There is
a national quality improvement project underway to
optimise pre-operative anaemia in orthopaedic patients
[19]. Pre-operative anaemia increases the risk of exposure to
red blood cell transfusion and is a significant risk factor for
peri-operative morbidity and mortality [20]. Although the
World Health Organization defines anaemia as below
120 g.l
1
for women and 130 g.l
1
for men, consensus
guidance is that the threshold should be 130 g.l
1
for both
sexes [21]. Timely and effective management of pre-
operative anaemia may improve peri-operative morbidity
and functional outcomes [22, 23].
Postoperative anaemia may have significant
implications for patient recovery. Changes in Hb
concentration >50% from baseline or postoperative
Hb <70 gl
1
have been shown to be associated with
increased risk of postoperative ischaemic events in surgical
patients [24]. The association between postoperative
anaemia and functional recovery, including patient-
reported outcome measures following surgical
interventions, remains unclear [22]. Over 80% of patients in
our sample were anaemic postoperatively, which
demonstrates that a significant proportion of arthroplasty
patients are potentially at risk of adverse postoperative
recovery [25]. Large-scale observational studies using
epidemiological data are required to further investigate
whether this association exists.
Red blood cell transfusion rates in our sample (3.1%)
were lower than previously reported results from national
datasets (18.3–47%) [26], but higher than some institutional
cohort studies [2]. Transfusion rates in total joint arthroplasty
have changed significantly in the past two decades with
development and uptake of patient blood management
strategies [27]. Restrictive transfusion thresholds have been
demonstrated to reduce rates of allogeneic transfusion with
no adverse effect on patient morbidity and mortality [28].
NICE recommends transfusion thresholds of 70 g.l
1
except in patients with acute coronary syndrome when the
threshold is 80 g.l
1
[7]. Transfusion rates following
unicompartmental knee arthroplasty (4.1%) were higher
than anticipated; however, the cohort included only 74
patients undergoing this procedure with three allogeneic
blood transfusions and is likely to represent sampling bias.
There is regional variation in the prevalence of pre-
operative anaemia and rate of postoperative transfusion.
Conclusions are limited by the small number of patients in
some regions; however, the results suggest heterogeneity
in the delivery of patient blood management despite
national guidelines [7].
Strengths of this study include utilising the power of a
trainee collaborative network [29, 30] to collect data on
current UK orthopaedic practice covering a wide
©2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Associat ion of Anaesthetists 7
Lloyd et al. | Peri-operative tranexamic acid in orthopaedic surgery Anaesthesia 2020
geographical area and 56 different NHS hospitals (Fig. 1).
Approximately 130,000 primary hip and knee replacements
are performed in NHS hospitals in 2018 [31]. Our study is
estimated to have captured over a third of procedures
performed during the period of study.
Our study also has limitations. Despite widespread
collaborator recruitment and data acquisition, it is possible
that the participating centres do not represent national
practice. Selection bias may favour hospitals with
established patient blood management programmes,
underestimating allogeneic transfusion rates amongst
arthroplasty patients. The calculation of blood loss is an
estimation, although Gross’formula is a validated and
accurate tool. Compliance with NICE guidance for
administering tranexamic acid may be higher than we
report, as we did not collect data to explain why tranexamic
acid was not administered. Relative contraindications to
tranexamic acid administration include thromboembolic
events and history of convulsion. Data on modes of
anaesthesia and patient comorbidity were not collected as
we focused on a small set of variables to enhance
recruitment.
In summary, we show good compliance with NICE
standards on tranexamic acid administration. The most
frequently adopted dosing regimen was 1000 mg
delivered intravenously as a single dose either pre-
operatively or intra-operatively. Future research studies may
wish to adopt this as a comparator to reduce study
heterogeneity that currently limits meta-analyses in this
field.
Acknowledgements
We thank Dr A. Shah for his help with the preparation and
critical appraisal of this manuscript. Funding support for this
study was received from the National Institute for Health
Research (NIHR) Oxford Biomedical Research Centre. No
other external funding or competing interests declared.
Appendix: collaborators.
J. Wong, P. Sharma, P. K. Osei-Bonsu, G. Ashcroft
(Aberdeen Royal Infirmary/Woodend General Hospital); T.
Baigent, E. Shirland (Addenbrooke’s Hospital); R. Espey,
M. Stokes (Altnagelvin Area Hospital); I. Liew, A. Dhawal,
D. Watchorn (Arrowe Park/Clatterbridge Hospitals); J.
Lum, M. Qureshi, A. S. Khaled (Blackpool Victoria
Hospital); S. Kauser (Bradford Royal Infirmary); G.
Hodhody, S. Rogers, B. Haywood-Alexander, G. Sheikh
(Burnley General Hospital/Royal Blackburn Hospital); P.
Mahapatra, H. Twaij, M. Chicco (Central Middlesex
Hospital); F. Arnaout, T. Atherton, J. Mutimer (Cheltenham
General Hospital); P. Sinha, E. Oliver (Darent Valley
Hospital); T. Stedman, R. Gadd (Doncaster Royal Infirmary);
V. Kutuzov, M. Sattar (Dr Gray’s Hospital); L. Robiati (Royal
Infirmary of Edinburgh; Victoria Hospital, Kirkcaldy); Ricci
Plastow (Fairfield General Hospital); T. Howe, A. Hassan
(Frimley Park Hospital); B. Lau, J. Collins (Guy’s and St.
Thomas’Hospital); A. Doshi (Hull Royal Infirmary); G. Tan,
D. Baskaran, K. Hari Sunil Kumar (Ipswich Hospital); R.
Agarwal (Llandough Hospital); M. Horner, R. Gwyn, S.
Masud (Morriston Hospital); O. Beaumont (Musgrove Park
Hospital); A. Pilarski (New Cross Hospital); M. Lebe, S.
Dawson-Bowling, D. Nolan, K. Tsitskaris (Newham General
Hospital); R. E. Beamish, C. Jordan, S. Alsop, E. Hibbert, G.
Deshpande, A. Gould, T. Briant-Evans, L. Kilbane (North
Hampshire General Hospital); I. Crowther, H. Ingoe, A.
Naisbitt (Northumbria Healthcare NHS Trust); L. Gourbault,
J. Muscat, E. L. Goh, (Nuffield Orthopaedic Centre); J. Gill,
M. Elbashir, N. Modi (Peterborough City Hospital); J.
Archer (Princess Royal Hospital Telford); S. Ismael (Russel
Hall Hospital); M. Petrie, H. O’Brien (Rotherham General
Hospital); M. McCormick, N. P. Koh (Royal Alexandra
Hospital); T. Lloyd (Royal Berkshire Hospital); A. King
(Royal Cornwall Hospital); A. Ikram, J. Peake (Royal Derby
Hospital); A. Yoong, D. S. Rye (Royal Devon and Exeter
Hospital); M. Newman (Royal Hampshire County Hospital);
A. Naraen, D. Myatt (Royal Preston Hospital); R. Kapur, P.
Sgardelis (Royal United Hospital); S. Kohli, M.
Culverhouse-Mathews (Salisbury District Hospital); S.
Haynes, H. Boden, A. Purmah (Sandwell District General
Hospital); R. Shenoy, S. Raja (Southend Hospital); N. P. Koh
(Southern General Hospital/Queen Elizabeth University
Hospital); R. Donovan, D. Yeomans, D. Ritchie, R. Larkin
(Southmead Hospital); R. Aladwan, K. Hughes (St. Richard’s
Hospital); R. Unsworth, R. Cooke, I. Samra, J. Barrow, K
Michael, F. Byrne (Stepping Hill Hospital); R. Anwar, L.
Karatzia, H. Drysdale, H. Wilson (Stoke Mandeville
Hospital/Wycombe General Hospital); R. Jones (Torbay
Hospital); D. Dass, F. Liaw (University Hospital of North
Staffordshire); R. Aujla, A. Kheiran (University Hospitals of
Leicester NHS Trust); K. Bell (Victoria Hospital, Kirkcaldy);
A. L. Ramavath, R. Telfer (Whiston Hospital); K. Nachev
(William Harvey Hospital); H. Lawrence, V. Garg, P. Shenoy,
A. Lacey, I. Byrom, M. Simons (Wrexham Maelor Hospital);
C. Manning, N. Cheyne, J. Williams (Wythenshawe
Hospital).
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Supporting Information
Additional supporting information may be found online via
the journal website.
Table S1. Pre-operative anaemia prevalence by
geographical region
Table S2. Incidence of allogeneic transfusion by
geographical region
©2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Associat ion of Anaesthetists 9
Lloyd et al. | Peri-operative tranexamic acid in orthopaedic surgery Anaesthesia 2020