Tranexamic Acid to Reduce Delirium After Gastrointestinal Surgery: the TRIGS-D Trial (TRIGS-D)

Tranexamic Acid to Reduce Delirium After Gastrointestinal Surgery: the TRIGS-D Trial (a Substudy of the TRIGS Trial)

Prophylactic TxA administration in patients undergoing major gastrointestinal surgery reduces the incidence of delirium after surgery when compared with placebo. The unifying hypothesis is that systemic and neuro-inflammation lead to neuronal injury and resultant postoperative delirium.

Delirium is a devastating complication of medical and perioperative care, associated with increased morbidity and mortality, dementia and impaired long-term cognition, and loss of independence. Delirium is also associated with neuronal injury placing patients at risk for long-term changes in cognition. There are no proven therapies for postoperative delirium, mainly due to the lack of adequately powered, biologically plausible trials. There is growing evidence that tranexamic acid (TxA) may reduce inflammatory pathways in the central nervous system and protect the blood-brain barrier in trauma, and surgery. This sub-study of the TRIGS trial (www.trigs.com.au) is evaluating the potential impact of TxA on the incidence and severity of delirium after surgery. TRIGS-D Study Aims: In a subset of 826 patients enrolled in the TRIGS randomized trial data will be collected to identify delirium incidence and severity. The specific aims are to investigate whether TxA: Aim 1: Reduces the incidence of postoperative delirium diagnosed with the 3D-CAM. Aim 2: Reduces the severity of delirium diagnosed with the 3D-CAM-Severity (3D-CAM-S). Aim 3: Modulates inflammatory (plasma cytokines, innate cell immune profile) and neurophysiological (EEG) responses in concert with any alteration in the incidence or severity of delirium. Aim 4: Reduces longer-term impairment of quality of life and improves disability-free survival. Primary hypothesis: Prophylactic TxA administration in patients undergoing major gastrointestinal surgery reduces the incidence of delirium after surgery when compared with placebo. The unifying hypothesis is that systemic and neuro-inflammation lead to neuronal injury and resultant postoperative delirium. Study Design: Multicentre, randomized, triple-blind, placebo-controlled, clinical trial (a sub-study of the TRIGS trial). Patients are randomly assigned to either TxA or matched placebo. The incidence of postoperative delirium will be assessed daily using the 3D-CAM or CAM-ICU and medical record review for the first 3 days after surgery. In addition, follow up assessments will be done at 30 days and 12 months.

Multicentre, randomised, triple-blind, placebo-controlled, clinical trial (a substudy of the TRIGS trial).

Intervention is from the Tranexamic acid to Reduce Infection after Gastrointestinal Surgery: the TRIGS Trial. A multicentre, pragmatic, double-blind, randomised clinical trial will compare the incidence of surgical site infection and red cell transfusion requirements after IV tranexamic acid and placebo in patients undergoing gastrointestinal surgery

3D-Confusion Assessment Method (3D-CAM) or CAM-ICU if the Used to measure delirium. Assessments will be conducted twice daily A classification of delirium will be made if both features 1 and 2 are present

post surgical incision to day 3 (at anytime)obtaining information from the patient, family and staff, and thorough chart review

using the Short form survey 12 - Quality of Life Intergroup differences in long-term (12 month) in perioperative cognitive decline

World Health Organization disability assessment schedule. Intergroup differences in long-term (12 month) in perioperative cognitive decline

NCD will be defined as any of: (i) subjective complaint, (ii) a 4-point reduction in TICS-B, (iii) SF or VF, and (iv) functional deficit defined as a reduction in WHODAS score of 5% or more from baseline (before surgery).

DAH30 is patient-centred and reflects the patient's primary aim of a healthy recovery, reduced hospital costs and serious complications, and avoiding re-admission (often due to postoperative delirium).

used to evaluate temporal changes in the innate cellular immune and inflammatory profile, and for changes in fibrinolysis

Inclusion criteria Adult patients scheduled for elective gastrointestinal (oesophageal, gastric, hepatobiliary, colorectal) surgery with 2 or more risk factors for complications: age ≥70 years, American Society of Anesthesiologists (ASA) physical status 3 or 4, heart failure, diabetes, chronic respiratory disease, obesity (BMI ≥30 kg/m2), vascular disease, preoperative haemoglobin <100 g/L, renal impairment (se. creatinine ≥150 micromol/L), or low albumin (<30 g/L). Written informed consent will be obtained. Exclusion criteria Poor spoken and/or written language comprehension, laparoscopic and other minor (eg. closure of stoma) surgery, pre-existing infection/sepsis, history of spontaneous pulmonary embolism or arterial thrombosis, current arterial or venous thrombosis, familial thrombophilia (e.g. Lupus anticoagulant, protein C deficiency, factor V Leiden), contraindication to TxA.