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Vrontis K, Tsinaslanidis G, Drosos GI, Tzatzairis T. Perioperative Blood Management Strategies for Patients Undergoing Total Hip Arthroplasty: Where Do We Currently Stand on This Matter? THE ARCHIVES OF BONE AND JOINT SURGERY 2020; 8:646-655. [PMID: 33313343 DOI: 10.22038/abjs.2020.45651.2249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Total hip replacement (THR) has proved to be a reliable treatment for the end stage of hip osteoarthritis. It is a common orthopaedic procedure with excellent results, but is associated with significant blood loss and high rates of allogeneic blood transfusion (ABT). The potential complications and adverse events after ABT, combined with the ongoing research, have resulted in multimodel, multidisciplinary blood management strategies adoption, aiming to reduce the blood loss and transfusion rates. Many reviews and meta-analyses have tried to demonstrate the best blood management strategies. The purpose of this study is to review any evidence-based blood conserving technique, dividing them in three stages: preoperative, intraoperative and postoperative.
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Affiliation(s)
| | | | - Georgios I Drosos
- Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Dragana, Greece
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Evaluating the safety of early surgery for ruptured intracranial aneurysms in patients with long-term aspirin use: a propensity score matching study. Chin Neurosurg J 2020; 6:37. [PMID: 33292864 PMCID: PMC7702666 DOI: 10.1186/s41016-020-00216-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/06/2020] [Indexed: 12/30/2022] Open
Abstract
Background Early microsurgical clipping is recommended for ruptured intracranial aneurysms to prevent rebleeding. However, dilemma frequently occurs when managing patients with current acetylsalicylic acid (aspirin) use. This study aimed to examine whether aspirin use was associated with worse outcomes after early surgery for aneurysmal subarachnoid hemorrhage (aSAH). Methods We retrieved a consecutive series of 215 patients undergoing early microsurgical clipping within 72 h after aneurysmal rupture from 2012 to 2018 in the neurosurgery department of Beijing Tiantan Hospital. The medical records of each case were reviewed. Twenty-one patients had a history of long-term aspirin use before the onset of aSAH, and 194 patients did not. To reduce confounding bias, propensity score matching (PSM) was performed to balance some characteristics of the two groups. The intraoperative blood loss, postoperative hemorrhagic events, postoperative hospital stay, and functional outcome at discharge were compared between aspirin and non-aspirin group. Results We matched all the 21 patients in aspirin group with 42 patients in non-aspirin group (1:2). Potential confounding factors were corrected between the two groups by PSM. No hospital mortality occurred after surgery. No significant differences were found in intraoperative blood loss (P = 0.540), postoperative hemorrhagic events (P > 0.999), postoperative hospital stay (P = 0.715), as well as functional outcome at discharge (P = 0.332) between the two groups. Conclusions Our preliminary results showed that long-term low-dose aspirin use was not associated with worse outcomes. Early surgery can be safe for ruptured intracranial aneurysms in patients with long-term aspirin use.
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Lim H, Gong EJ, Min BH, Kang SJ, Shin CM, Byeon JS, Choi M, Park CG, Cho JY, Lee ST, Kim HG, Chun HJ. Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy. Clin Endosc 2020; 53:663-677. [PMID: 33242928 PMCID: PMC7719428 DOI: 10.5946/ce.2020.192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Byung-Hoon Min
- Department of Gastroenterology, Samsung Medical Center, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chan Guk Park
- Department of Gastroenterology, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha University Bundang Medical Center, Seongnam, Korea
| | - Soo Teik Lee
- Department of Gastroenterology, Jeonbuk National Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Department of Gastroenterology, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea
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Gerstein NS, Albrechtsen CL, Mercado N, Cigarroa JE, Schulman PM. A Comprehensive Update on Aspirin Management During Noncardiac Surgery. Anesth Analg 2020; 131:1111-1123. [PMID: 32925332 DOI: 10.1213/ane.0000000000005064] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aspirin is considered critical lifelong therapy for patients with established cardiovascular (CV) disease (including coronary artery, cerebrovascular, and peripheral arterial diseases) and is consequently one of the most widely used medications worldwide. However, the indications for aspirin use continue to evolve and recent trials question its efficacy for primary prevention. Although one third of patients undergoing noncardiac surgery and at risk for a major adverse CV event receive aspirin perioperatively, uncertainty still exists about how aspirin should be optimally managed in this context, and significant practice variability remains. Recent trials suggest that the risks of continuing aspirin during the perioperative period outweigh the benefits in many cases, but data on patients with high CV risk remain limited. We performed a comprehensive PubMed and Medline literature search using the following keywords: aspirin, aspirin withdrawal, perioperative, coronary artery disease, cerebrovascular disease, peripheral artery disease, and CV disease; we manually reviewed all relevant citations for inclusion. Patients taking aspirin for the primary prevention of CV disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding. Patients with established CV disease but without a coronary stent should likely continue aspirin during the perioperative period unless undergoing closed-space surgery. Patients with a history of coronary stenting also likely need aspirin continuation throughout the perioperative period for nonclosed space procedures. Perioperative clinicians need to balance the risks of ceasing aspirin before surgery against its continuation during the perioperative interval using a patient-specific strategy. The guidance on decision-making with regard to perioperative aspirin cessation or continuation using currently available clinical data from studies in high-risk patients along with nonclinical aspirin studies is conflicting and does not enable a simplified or unified answer. However, pertinent guidelines on CV disease management provide a basic framework for aspirin management, and large trial findings provide some insight into the safety of perioperative aspirin cessation in some contexts, although uncertainty on perioperative aspirin still exists. This review provides an evidence-based update on perioperative aspirin management in patients undergoing noncardiac surgery with a focus on recommendations for perioperative clinicians on continuing versus holding aspirin during this context.
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Affiliation(s)
- Neal S Gerstein
- From the Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Nestor Mercado
- Division of Cardiology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Peter M Schulman
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
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Cold Snare Polypectomy in Patients Taking Dual Antiplatelet Therapy: A Randomized Trial of Discontinuation of Thienopyridines. Clin Transl Gastroenterol 2020; 10:e00091. [PMID: 31599746 PMCID: PMC6884347 DOI: 10.14309/ctg.0000000000000091] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION: Cold snare polypectomy (CSP) is a safe and effective method for removing polyps ≤10 mm. The aim of this study was to compare the risk of clinically significant bleeding and thromboembolic events after CSP between stopping and continuing thienopyridines in patients taking dual antiplatelet therapy (DAPT). METHODS: The study was a single-center, noninferiority, and randomized controlled study involving patients who received colonoscopy from October 2015 to October 2016. Patients receiving DAPT with polyps ≤10 mm were randomly assigned to either the DAPT group (patients continued DAPT) or the aspirin group (patients discontinued thienopyridines for 1 week). Primary outcome was clinically significant bleeding. Secondary outcomes included intraprocedural bleeding, nonsignificant hematochezia, and occurrence of thromboembolic events. RESULTS: Forty-two patients with 104 eligible polyps were allocated to the DAPT group, and 45 patients with 101 eligible polyps were allocated to the aspirin group. Patient demographic characteristics including size, location, shape, and pathology of the removed polyps were similar in the 2 groups. Intraprocedural bleeding and nonsignificant hematochezia rates were also similar between the 2 groups (4.8% vs 2.2%, P = 0.608; 19.0% vs 8.9%, P = 0.170). No thromboembolic event occurred in either group. Only 1 patient (2.4%) in the DAPT group showed clinically significant bleeding. No significant bleeding was found in the aspirin group. DISCUSSION: Clinically significant bleeding rate after CSP for polyps ≤10 mm in patients continuing to take DAPT was 2.4%. Therefore, CSP is a safe method for removing small polyps even in patients taking DAPT (ClincialTrials.gov number, NCT02865824).
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Lee JH, Jo SH. Preoperative Cessation of Both Dual Anti-Platelet Agents Is Safe after 1 Year in Patients Receiving Percutaneous Coronary Intervention. J Lipid Atheroscler 2020; 9:304-312. [PMID: 32821739 PMCID: PMC7379090 DOI: 10.12997/jla.2020.9.2.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/30/2020] [Accepted: 05/13/2020] [Indexed: 11/09/2022] Open
Abstract
Objective The aim of this study was to investigate the atherothrombotic and bleeding risk of discontinuing both components of dual antiplatelet therapy (DAPT) before surgery in patients with an intracoronary stent after 1 year. Methods We retrospectively enrolled 212 patients who received an evaluation of perioperative cardiac risk and underwent surgery from March 2017 to March 2019. We divided them into 2 groups: the discontinuation of both antiplatelet agents group (DCAP, no use of any antiplatelet agent) and the continuation of at least 1 antiplatelet agent group (CAP). The primary composite endpoint was the occurrence of major adverse cardiovascular events (MACE), including death, angina, postoperative coronary angiography, stroke, and readmission within 30 days postoperatively. The second endpoint was bleeding requiring the transfusion of ≥2 packs of red blood cells (RBCs). Result A total of 136 patients were enrolled in the study, with 68 in the DCAP group and 68 in the CAP group. The occurrence of MACE did not significantly differ between the groups (25% vs. 17.6%, p=0.295). The incidence of bleeding that required a transfusion was higher in the CAP group (16.2% vs. 30.9%, p=0.044). The postoperative change in hemoglobin levels (-1.9 g/dL vs. -1.8 g/dL, p=0.742), and the number of transfused packs of RBCs (3.5 vs. 5.3, p=0.347) were not significantly different between the groups. Conclusion Preoperative discontinuation of DAPT did not increase the risk of MACE. However, continuation of at least 1 antiplatelet agent increased the incidence of bleeding requiring RBC transfusion. Further research with a large cohort is warranted.
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Affiliation(s)
- Jeen Hwa Lee
- Division of Cardiology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sang Ho Jo
- Division of Cardiology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
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Zakaryan A, Ginosyan K. Perioperative Management of Patients With Ankylosing Spondylitis Undergoing Spine Surgery. Front Pharmacol 2020; 11:1017. [PMID: 32742263 PMCID: PMC7364138 DOI: 10.3389/fphar.2020.01017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/23/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Arman Zakaryan
- Department of Neurosurgery, Yerevan State Medical University after Mkhitar Heratsi, Yerevan, Armenia
| | - Knarik Ginosyan
- Department of Rheumatology, Yerevan State Medical University after Mkhitar Heratsi, Yerevan, Armenia
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Takahashi R, Fujikawa T. Impact of perioperative aspirin continuation on bleeding complications in laparoscopic colorectal cancer surgery: a propensity score-matched analysis. Surg Endosc 2020; 35:2075-2083. [PMID: 32372221 DOI: 10.1007/s00464-020-07604-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 04/28/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND In laparoscopic surgery for colorectal cancer (CRC) for patients who receive antiplatelet therapy (APT), it remains unclear whether APT should be continued or temporarily withdrawn. We investigated the safety of perioperative aspirin continuation, specifically focused on bleeding complications. METHODS We performed retrospective analysis utilizing propensity score-matching (PSM). In total, 789 patients satisfied the inclusion criteria, and were divided into two groups. Patients in the continued aspirin monotherapy (cAPT) group continued treatment perioperatively with not more than 2 days of withdrawal (n = 140). Patients with more than 3 days withdrawal of aspirin or who did not receive APT at all were assigned to the non-cAPT group (n = 649). After 1:1 PSM, 105 patients were extracted from each group. Perioperative APT management was determined based on our institutional committee-approved guidelines for antithrombotic management. RESULTS In PSM cohorts, all patient demographics were comparable between the groups. Regarding intraoperative outcomes, we found no significant difference in operation duration (p = 0.969), blood loss (p = 0.068), and blood transfusion (p = 0.517). Postoperative overall morbidity was 20.0% and 13.3% in the cAPT and non-cAPT groups, respectively (p = 0.195). The incidence of bleeding complications was also comparable between the groups (2.9% vs. 1.0%, p = 0.317). Assessing the 14 cases with bleeding complications overall in the full cohort, all 7 cases in the non-cAPT group had anastomotic bleeding, which was generally observed shortly after surgery [median postoperative day (POD) 1]. All 7 cases in the cAPT group received additional antithrombotics other than aspirin; bleeding occurred at various sites relatively later (median POD 7), mostly after reinstitution of additional antithrombotic agents. CONCLUSIONS For patients receiving APT, perioperative continuation of aspirin monotherapy could be safe in laparoscopic CRC surgery; however, careful consideration is required at reinstitution of additional antithrombotics where multiple antithrombotic agents are used.
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Affiliation(s)
- Ryo Takahashi
- Department of Surgery, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu, Fukuoka, 8028555, Japan
| | - Takahisa Fujikawa
- Department of Surgery, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu, Fukuoka, 8028555, Japan.
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Scibelli G, Maio L, Savoia G. Corrected and republished from: Regional anesthesia and antithrombotic agents: instructions for use. Minerva Anestesiol 2020; 86:341-353. [DOI: 10.23736/s0375-9393.20.14494-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Fujikawa T, Kawamura Y, Takahashi R, Naito S. Risk of postoperative thromboembolic complication after major digestive surgery in patients receiving antiplatelet therapy: Lessons from more than 3,000 operations in a single tertiary referral hospital. Surgery 2020; 167:859-867. [PMID: 32087945 DOI: 10.1016/j.surg.2020.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/09/2020] [Accepted: 01/11/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although recent studies have suggested that the continuation of preoperative antiplatelet therapy with aspirin does not affect intraoperative or postoperative bleeding in patients undergoing digestive surgery, its preventive effect against thromboembolic complication remains largely unknown. METHODS A total of 3,072 patients who underwent major digestive surgery (esophago-gastrointestinal and hepatobiliary-pancreatic resection for malignancy) between 2005 and 2018 at our institution were enrolled in this study. The patients were divided into 3 groups: patients continuing to receive preoperative antiplatelet therapy with aspirin (continued-antiplatelet therapy group, n = 425), those discontinuing preoperative antiplatelet therapy (discontinued-antiplatelet therapy group, n = 549), and those who were not receiving antiplatelet therapy (non-antiplatelet therapy group, n = 2,117). The CHADS2 and the CHA2DS2-VASc scoring system were used to assess potential thromboembolic risk. Surgical outcomes were compared between the groups and the risk factors for thromboembolic complication, bleeding complication, and operative mortality were determined by multivariate analysis. RESULTS There was no difference between the discontinued-antiplatelet therapy and continued-antiplatelet therapy groups in the rate of high risk patients categorized by CHADS2 and CHA2DS2-VASc scores; however, the occurrence of thromboembolic complication in the discontinued-antiplatelet therapy group was significantly higher compared with the continued-antiplatelet therapy group (2.8% vs 0.5%; P = .006). In a multivariate analysis using the whole cohort, discontinuation of antiplatelet therapy (odds ratio = 4.39; P < .001), poor performance status (odds ratio = 4.14; P = .001), and hypertension (odds ratio = 3.46; P = .005) were the independent risk factors for thromboembolic complication. In the groups of patients receiving antiplatelet therapy, multivariate analysis showed that preoperative aspirin continuation had a significant negative impact (odds ratio = 0.10, P = .029) on the occurrence of thromboembolic complication, but did not affect either postoperative bleeding complication or operative mortality. CONCLUSION Discontinuation of antiplatelet therapy during major digestive surgery is the most significant risk factor for thromboembolic complication, and the continuation of preoperative aspirin therapy significantly reduces the occurrence of thromboembolic complication in patients receiving antiplatelet therapy. It is suggested that the preoperative continuation of aspirin monotherapy is one of the preferred options to prevent severe thromboembolic events during major digestive surgery in patients receiving antiplatelet therapy.
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Affiliation(s)
- Takahisa Fujikawa
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan.
| | - Yuichiro Kawamura
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Ryo Takahashi
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Shigetoshi Naito
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
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Abstract
Myocardial injury after noncardiac surgery (MINS) is a common postoperative complication associated with adverse cardiovascular outcomes. The purpose of this systematic review was to determine the incidence, clinical features, pathogenesis, management, and outcomes of MINS. We searched PubMed, Embase, Central and Web of Science databases for studies reporting the incidence, clinical features, and prognosis of MINS. Data analysis was performed with a mixed-methods approach, with quantitative analysis of meta-analytic methods for incidence, management, and outcomes, and a qualitative synthesis of the literature to determine associated preoperative factors and MINS pathogenesis. A total of 195 studies met study inclusion criteria. Among 169 studies reporting outcomes of 530,867 surgeries, the pooled incidence of MINS was 17.9% [95% confidence interval (CI), 16.2-19.6%]. Patients with MINS were older, more frequently men, and more likely to have cardiovascular risk factors and known coronary artery disease. Postoperative mortality was higher among patients with MINS than those without MINS, both in-hospital (8.1%, 95% CI, 4.4-12.7% vs 0.4%, 95% CI, 0.2-0.7%; relative risk 8.3, 95% CI, 4.2-16.6, P < 0.001) and at 1-year after surgery (20.6%, 95% CI, 15.9-25.7% vs 5.1%, 95% CI, 3.2-7.4%; relative risk 4.1, 95% CI, 3.0-5.6, P < 0.001). Few studies reported mechanisms of MINS or the medical treatment provided. In conclusion, MINS occurs frequently in clinical practice, is most common in patients with cardiovascular disease and its risk factors, and is associated with increased short- and long-term mortality. Additional investigation is needed to define strategies to prevent MINS and treat patients with this diagnosis.
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Kuthiah N, Er C. Myocardial injury in non-cardiac surgery: complexities and challenges. Singapore Med J 2020; 61:6-8. [DOI: 10.11622/smedj.2020004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Swan D, Loughran N, Makris M, Thachil J. Management of bleeding and procedures in patients on antiplatelet therapy. Blood Rev 2020; 39:100619. [DOI: 10.1016/j.blre.2019.100619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/31/2019] [Accepted: 10/10/2019] [Indexed: 02/06/2023]
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Raggio BS, Barton BM, Kandil E, Friedlander PL. Association of Continued Preoperative Aspirin Use and Bleeding Complications in Patients Undergoing Thyroid Surgery. JAMA Otolaryngol Head Neck Surg 2019; 144:335-341. [PMID: 29494736 DOI: 10.1001/jamaoto.2017.3262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance No evidence exists to direct the management of preoperative aspirin (acetylsalicylic acid) use in patients undergoing thyroid surgery. Nevertheless, a considerable number of patients interrupt receiving aspirin therapy during the preoperative period to minimize bleeding complications despite the increased risk of experiencing major adverse cardiac events. Objective To determine whether aspirin therapy continued preoperatively increases bleeding complications in patients undergoing thyroid surgery. Design, Setting, and Participants Retrospective analysis of a consecutive sample of 570 patients, aged 18 to 100 years, who underwent thyroid surgery for benign and malignant disease from January 1, 2010, to December 31, 2015, by a single surgeon at a tertiary referral hospital center in New Orleans, Louisiana. Exposures Patients receiving aspirin therapy and patients not receiving aspirin therapy (aspirin naive) preoperatively. Main Outcomes and Measures Comparison of estimated blood loss, substantial blood loss, operative hematoma, nonoperative hematoma, and recurrent laryngeal nerve injury. Results Of 570 patients who underwent thyroid surgery, 106 (18.6%) were performed in patients receiving aspirin; of these, 23 (21.7%) were men and 105 (99.1%) were older than 45 years. Those receiving aspirin therapy displayed a 14.4-year difference in age (95% CI, 11.6-17.1). The aspirin group displayed a 20.3% absolute increase (95% CI, 9.3-30.7) in African American patients. Aspirin therapy was not associated with a statistically significant or clinically meaningful increase in intraoperative blood loss (2.5 mL; 95% CI, -0.4 to 5.3). Aspirin therapy was associated with a statistically significant increase in total hematoma formation (3.3%; 95% CI, 0.4-9.0), but the results were inconclusive. Aspirin therapy was not associated with a statistically significant increase in recurrent laryngeal nerve injury (2.6%; 95% CI, -1.1 to 8.6), but the results were inconclusive. Conclusions and Relevance These results suggest that aspirin therapy can be maintained prior to thyroid surgery without increased intraoperative bleeding. Further research with a larger sample size and more outcome events are required to make definitive conclusions regarding the association between aspirin use and complications, including hematoma and recurrent laryngeal nerve injury.
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Affiliation(s)
- Blake S Raggio
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
| | - Blair M Barton
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
| | - Emad Kandil
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
| | - Paul L Friedlander
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
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Cholette JM, Faraoni D, Goobie SM, Ferraris V, Hassan N. Patient Blood Management in Pediatric Cardiac Surgery: A Review. Anesth Analg 2019; 127:1002-1016. [PMID: 28991109 DOI: 10.1213/ane.0000000000002504] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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Affiliation(s)
- Jill M Cholette
- From the Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts.,Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Ferraris
- Department of Surgery, University of Kentucky Chandler Medical Center & Lexington Veterans Affairs Medical Center, Lexington, Kentucky
| | - Nabil Hassan
- Division of Pediatric Critical Care, Children's Hospital of Illinois At OSF St Frances, University of Illinois at Peoria, Peoria, Illinois
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Robbins SL, Wang JW, Frazer JR, Greenberg M. Anticoagulation: a practical guide for strabismus surgeons. J AAPOS 2019; 23:193-199. [PMID: 30981895 DOI: 10.1016/j.jaapos.2018.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 12/04/2018] [Accepted: 12/09/2018] [Indexed: 01/08/2023]
Abstract
An increasing number of surgical strabismus patients are taking oral anticoagulant and antiplatelet agents, with more diverse mechanisms of action than those used in the past. The decision as to whether to continue these drugs throughout the perioperative period is difficult and must be based on the balance between hemorrhagic and thrombotic risk. To help guide strabismus surgeons with clinical management in these cases, we review potential hemorrhagic complications of strabismus surgery and examine the use of anticoagulant and antiplatelet drugs during the perioperative period. Surgical strategies that might help minimize intraoperative hemorrhage in patients on anticoagulant therapy are also discussed.
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Affiliation(s)
- Shira L Robbins
- Viterbi Family Department of Ophthalmology, University of California, San Diego; Ratner Children's Eye Center at the Shiley Eye Institute, University of California, San Diego.
| | - Jeffrey W Wang
- Viterbi Family Department of Ophthalmology, University of California, San Diego
| | | | - Mark Greenberg
- Department of Anesthesia, University of California, San Diego
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Li J, Wang M, Cheng T. The safe and risk assessment of perioperative antiplatelet and anticoagulation therapy in inguinal hernia repair, a systematic review. Surg Endosc 2019; 33:3165-3176. [DOI: 10.1007/s00464-019-06956-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/01/2019] [Indexed: 01/30/2023]
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68
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Godier A, Garrigue D, Lasne D, Fontana P, Bonhomme F, Collet JP, de Maistre E, Ickx B, Gruel Y, Mazighi M, Nguyen P, Vincentelli A, Albaladejo P, Lecompte T. Management of antiplatelet therapy for non elective invasive procedures of bleeding complications: proposals from the French working group on perioperative haemostasis (GIHP), in collaboration with the French Society of Anaesthesia and Intensive Care Medicine (SFAR). Anaesth Crit Care Pain Med 2019; 38:289-302. [DOI: 10.1016/j.accpm.2018.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/07/2018] [Indexed: 12/12/2022]
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69
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Yasukawa M, Taiji R, Marugami N, Kawaguchi T, Kawai N, Sawabata N, Tojo T, Takahama J, Hamazaki N, Hirai T, Taniguchi S. Ultrasonography for Detecting Adhesions: Aspirin Continuation for Lung Resection Patients. In Vivo 2019; 33:973-978. [PMID: 31028224 PMCID: PMC6559903 DOI: 10.21873/invivo.11566] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIM Aspirin reduces cardiovascular disease and/or stroke risks. However, perioperative aspirin use remains controversial. We assessed the efficacy of ultrasonography to facilitate video-assisted thoracic surgery (VATS). We analyzed the perioperative management of patients using aspirin and its association with bleeding events during lung cancer surgery. PATIENTS AND METHODS A total of 38 patients who underwent VATS after continuing or discontinuing aspirin were examined. Ultrasound was performed preoperatively to evaluate the pleural adhesions. Fisher's exact test was used to analyze correlations between the two groups. RESULTS Dense adhesions were found at VATS ports using ultrasonography (accuracy: 100%). No differences were detected in bleeding, thrombotic events, or operative times between the aspirin and non-aspirin groups. There were differences in bleeding (p=0.009) and operative times (p=0.021) between the dense adhesion and non-dense adhesion groups. CONCLUSION Preoperative detection of pleural adhesions using ultrasonography was useful in selecting pulmonary resection patients who continued aspirin perioperatively.
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Affiliation(s)
- Motoaki Yasukawa
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Ryosuke Taiji
- Department of Radiology, Saiseikai Chuwa Hospital, Nara, Japan
| | | | - Takeshi Kawaguchi
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Norikazu Kawai
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Noriyoshi Sawabata
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Takashi Tojo
- Department of Thoracic Surgery, Saiseikai Chuwa Hospital, Nara, Japan
| | - Junko Takahama
- Department of Radiology, Saiseikai Chuwa Hospital, Nara, Japan
| | | | - Toshiko Hirai
- Department of Endoscopy and Ultrasound, Nara Medical University School of Medicine, Nara, Japan
| | - Shigeki Taniguchi
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Nara, Japan
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Oakland K, Chadwick G, East JE, Guy R, Humphries A, Jairath V, McPherson S, Metzner M, Morris AJ, Murphy MF, Tham T, Uberoi R, Veitch AM, Wheeler J, Regan C, Hoare J. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019; 68:776-789. [PMID: 30792244 DOI: 10.1136/gutjnl-2018-317807] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/07/2019] [Accepted: 01/16/2019] [Indexed: 01/28/2023]
Abstract
This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). The Guidelines Development Group consisted of representatives from the BSG Endoscopy Committee, the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists, NHS Blood and Transplant and a patient representative. A systematic search of the literature was undertaken and the quality of evidence and grading of recommendations appraised according to the GRADE(Grading of Recommendations Assessment, Development and Evaluation) methodology. These guidelines focus on the diagnosis and management of acute LGIB in adults, including methods of risk assessment and interventions to diagnose and treat bleeding (colonoscopy, computed tomography, mesenteric angiography, endoscopic therapy, embolisation and surgery). Recommendations are included on the management of patients who develop LGIB while receiving anticoagulants (including direct oral anticoagulants) or antiplatelet drugs. The appropriate use of blood transfusion is also discussed, including haemoglobin triggers and targets.
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Affiliation(s)
| | | | - James E East
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford, UK
| | - Richard Guy
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Vipul Jairath
- Robarts Clinical Trials, Inc., London, Ontario, Canada.,Medicine and Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | | | - Magdalena Metzner
- Department of Gastroenterology, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - A John Morris
- Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Tony Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, UK
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - James Wheeler
- Department of Colorectal Surgery, Addenbrooke's Hospital, Cambridge, UK
| | | | - Jonathan Hoare
- Department of Surgery and Cancer, Imperial College, London, UK
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Hakuta R, Kogure H, Nakai Y, Hamada T, Noguchi K, Saito K, Saito T, Takahara N, Mizuno S, Yagioka H, Ito Y, Tada M, Isayama H, Koike K. Endoscopic papillary large balloon dilation without sphincterotomy for users of antithrombotic agents: A multicenter retrospective study. Dig Endosc 2019; 31:316-322. [PMID: 30586206 DOI: 10.1111/den.13326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/19/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM With an aging population, an increasing number of individuals on antithrombotic agents are diagnosed with large bile duct stones. Studies have shown the effectiveness of endoscopic papillary large balloon dilation (EPLBD) for removal of large bile duct stones. EPLBD without endoscopic sphincterotomy (EST) may reduce the risk of procedure-related bleeding, but the safety of this procedure for users of antithrombotic agents remains unclear. METHODS In this multicenter retrospective study, we included patients who underwent EPLBD without EST for bile duct stones between March 2008 and December 2017. We compared adverse events and other clinical outcomes between users and non-users of antithrombotic agents (antiplatelet agents and anticoagulants). RESULTS We analyzed a total of 144 patients (47 users and 97 non-users of antithrombotic agents). Among the users, the agents were continued in 13% and were replaced with heparin in 62% during the periprocedural period. We did not observe clinically significant bleeding and thrombotic events irrespective of the use of antithrombotic agents. Overall rate of early adverse events did not differ between users and non-users (6.4% and 7.2%, P = 0.99). Procedural outcomes did not differ between the groups (necessity for lithotripsy, 28% vs. 29%; and complete stone removal in a single session, 72% vs. 71%, for users and non-users, respectively). CONCLUSIONS Endoscopic papillary large balloon dilation without EST may be done without a substantial increase in procedure-related bleeding for users of antithrombotic agents. A larger study is required to refine the management strategy for those agents during the periprocedural period.
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Affiliation(s)
- Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kensaku Noguchi
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Valentine EA, Zhou EY, Gold AK, Ochroch EA. The Year in Vascular Anesthesia: Selected Highlights From 2018. J Cardiothorac Vasc Anesth 2019; 33:2826-2832. [PMID: 31138466 DOI: 10.1053/j.jvca.2019.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 04/11/2019] [Indexed: 11/11/2022]
Abstract
This special article is the second in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia that is specifically dedicated to highlights in vascular anesthesiology published in 2018. This review begins with 2 updates in preoperative medicine in the vascular surgery population, including recent publications regarding the management of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers and antiplatelet medications in the perioperative period. The next section focuses on complications related to thoracic endovascular aortic surgery, particularly as technology advances allow for endovascular repair of more complex anatomy. The final section focuses on quality in vascular surgery and evaluates recent publications that examine the safety and feasibility of fast-track endovascular aortic surgery. Even though this is only a sampling of the literature published in 2018 relevant to the cardiovascular anesthesiologist, these themes represent some of the topics most clinically relevant to the perioperative period.
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Affiliation(s)
- Elizabeth A Valentine
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Elizabeth Y Zhou
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Andrew K Gold
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
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Stamenovic D, Schneider T, Messerschmidt A. Aspirin for patients undergoing major lung resections: hazardous or harmless?†. Interact Cardiovasc Thorac Surg 2019; 28:535-541. [PMID: 30346533 DOI: 10.1093/icvts/ivy255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Acetylsalicylic acid (ASA, aspirin) is a medication widely used for primary and secondary prevention of cardiovascular diseases, which are the leading cause of morbidity and mortality worldwide. Whether aspirin should be continued or paused in the perioperative period remains controversial, especially in thoracic surgical settings. METHODS A single-centred retrospective study comprised 486 patients. Of these, 329 patients did not use aspirin (group ASA-0) and 157 did (group ASA-1) during the perioperative period after anatomical lung resection at our hospital from January 2013 to December 2016. Major outcome measures were the amount of blood loss during the operation and during the first 5 days postoperatively (per Mercuriali's formula), as well as the amount and proportion of the blood transfusion (packed red cells) received. The need for reoperation due to a postoperative haemothorax and/or bleeding was recorded. The groups were also compared according to their rates of morbidity and mortality. Inferential statistical methods with bootstrap analysis using 1000 samples and the Mersenne Twister, a random number generator, were used. RESULTS There were no significant differences between the 2 groups in intraoperative bleeding [ASA-0M = 418.69 ml, standard deviation (SD) ± 364.87; ASA-1M = 399.8 ml, SD ± 323.84; P = 0.58] or in total blood loss according to Mercuriali's formula (ASA-0M = 1111.62 ml, SD ± 816.69; ASA-1M = 1115.08 ml, SD ± 682.12; P = 0.95). A total of 104 patients received transfusions up to postoperative day 5: 71 patients in the ASA-0 group received 151 blood transfusions, whereas 33 patients in the ASA-1 group received 65 blood transfusions (P = 0.66). The indication for reoperation due to bleeding (ASA-1 = 3, ASA-0 = 4; P = 0.69) was similar between the groups. There was a trend towards higher rates of postoperative complications in the ASA-1 group (risk ratio (RR) = 1.28; P = 0.055); neither cardiovascular complications nor deaths were more frequent in either of the 2 groups (P = 0.73). CONCLUSIONS Patients taking aspirin therapy and undergoing anatomical lung resection seem not to be at any disadvantage regarding bleeding. However, a trend towards a higher rate of postoperative complications indicates a basically increased risk for operations due to comorbidities in these patients.
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Affiliation(s)
- Davor Stamenovic
- Department of Thoracic Surgery, ViDia Kliniken, Karlsruhe, Germany
| | - Thomas Schneider
- Department of Thoracic Surgery, ViDia Kliniken, Karlsruhe, Germany
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Goggs R, Blais MC, Brainard BM, Chan DL, deLaforcade AM, Rozanski E, Sharp CR. American College of Veterinary Emergency and Critical Care (ACVECC) Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE) guidelines: Small animal. J Vet Emerg Crit Care (San Antonio) 2019; 29:12-36. [PMID: 30654421 DOI: 10.1111/vec.12801] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/12/2018] [Accepted: 12/07/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To systematically review available evidence and establish guidelines related to the risk of developing thrombosis and the management of small animals with antithrombotics. DESIGN Standardized, systematic evaluation of the literature (identified by searching Medline via PubMed and CAB abstracts) was carried out in 5 domains (Defining populations at risk; Defining rational therapeutic use; Defining evidence-based protocols; Refining and monitoring antithrombotic therapies; and Discontinuing antithrombotic therapies). Evidence evaluation was carried out using Population, Intervention, Comparison, Outcome generated within each domain questions to address specific aims. This was followed by categorization of relevant articles according to level of evidence and quality (Good, Fair, or Poor). Synthesis of these data led to the development of a series of statements. Consensus on the final guidelines was achieved via Delphi-style surveys. Draft recommendations were presented at 2 international veterinary conferences and made available for community assessment, review, and comment prior to final revisions and publication. SETTINGS Academic and referral veterinary medical centers. RESULTS Over 500 studies were reviewed in detail. Worksheets from all 5 domains generated 59 statements with 83 guideline recommendations that were refined during 3 rounds of Delphi surveys. A high degree of consensus was reached across all guideline recommendations. CONCLUSIONS Overall, systematic evidence evaluations yielded more than 80 recommendations for the treatment of small animals with or at risk of developing thrombosis. Numerous significant knowledge gaps were highlighted by the evidence reviews undertaken, indicating the need for substantial additional research in this field.
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Affiliation(s)
- Robert Goggs
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, NY
| | - Marie-Claude Blais
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, QC, Canada
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA
| | - Daniel L Chan
- Department Clinical Science and Services, The Royal Veterinary College, London, United Kingdom
| | - Armelle M deLaforcade
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA
| | - Elizabeth Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA
| | - Claire R Sharp
- School of Veterinary and Life Sciences, College of Veterinary Medicine, Murdoch University, Murdoch, WA, Australia
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Brainard BM, Buriko Y, Good J, Ralph AG, Rozanski EA. Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 5-Discontinuation of anticoagulant therapy in small animals. J Vet Emerg Crit Care (San Antonio) 2019; 29:88-97. [PMID: 30654425 DOI: 10.1111/vec.12796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 12/10/2018] [Accepted: 12/08/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To systematically evaluate the evidence supporting the timing and mechanisms of permanent or temporary discontinuation of antiplatelet or anticoagulant medications in small animals DESIGN: Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality (poor, fair, or good), and development of consensus on conclusions via a Delphi-style survey for application of the concepts to clinical practice. SETTINGS Academic and referral veterinary medical centers. RESULTS Databases searched included Medline via PubMed and CAB abstracts. Two specific courses of inquiry were pursued, one focused on appropriate approaches to use for small animal patients receiving antiplatelet or anticoagulant drugs and requiring temporary discontinuation of this therapy for the purposes of invasive procedures (eg, surgery), and the other aimed at decision-making for the complete discontinuation of anticoagulant medications. In addition, the most appropriate methodology for discontinuation of heparins was addressed. CONCLUSIONS To better define specific patient groups, a risk stratification characterization was developed. It is recommended to continue anticoagulant therapy through invasive procedures in patients at high risk for thrombosis that are receiving anticoagulant therapy, while consideration for discontinuation in patients with low to moderate risk of thrombosis is reasonable. In patients with thrombosis in whom the underlying cause for thrombosis has resolved, indefinite treatment with anticoagulant medication is not recommended. If the underlying cause is unknown or untreatable, anticoagulant medication should be continued indefinitely. Unfractionated heparin therapy should be slowly tapered rather than discontinued abruptly.
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Affiliation(s)
- Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA
| | - Yekaterina Buriko
- Department of Clinical Studies, Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jennifer Good
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA
| | | | - Elizabeth A Rozanski
- Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA
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Godier A, Garrigue D, Lasne D, Fontana P, Bonhomme F, Collet JP, de Maistre E, Ickx B, Gruel Y, Mazighi M, Nguyen P, Vincentelli A, Albaladejo P, Lecompte T. Management of antiplatelet therapy for non-elective invasive procedures or bleeding complications: Proposals from the French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Thrombosis and Haemostasis (GFHT), in collaboration with the French Society for Anaesthesia and Intensive Care (SFAR). Arch Cardiovasc Dis 2019; 112:199-216. [DOI: 10.1016/j.acvd.2018.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/09/2018] [Indexed: 12/21/2022]
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Hill DA, Sleiman M, Castellano MR. Is the Perioperative Continuation of Antiplatelet Therapy Safe for Elective Hernia Surgery? Am Surg 2019. [DOI: 10.1177/000313481908500337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Antiplatelet medication use in the perioperative period for elective surgical procedures remains controversial. We hypothesized that for elective hernioplasty, the continuation of antiplatelet agents would not increase postoperative complications. A single surgeon prospectively tracked all elective hernia repairs performed. All patients were included except those on anticoagulation therapy. Patients already on antiplatelet therapy (APT) continued their regimen throughout the perioperative period, whereas those who were not remained off antiplatelet medications. All patients had postoperative visits between 7 and 10 days at which point they were evaluated with complications documented. One thousand four patients underwent open hernia repair. Two hundred sixty-seven patients were taking APT, whereas 737 were not. The mean age of the antiplatelet group was greater than those not on APT (66 vs 51 years old, P < 0.0001). Ecchymosis occurred more frequently in the APT group than in those not on APT (9.36% vs 2.71%, P = 0.0005). This was the only statistically significant difference in postoperative complications noted between these two groups. Patients taking clopidogrel alone or a combination of aspirin and clopidogrel had a significantly higher rate of ecchymosis compared with those on other antiplatelet regiments (10%, 21.6%, and 7.4%, respectively, P = 0.047). There were no postoperative hematomas, bleeding complications, urinary retention, or any patients who required cessation of antiplatelet medications. Continuation of APT in the perioperative period for elective hernia repair did not result in an increased frequency of postoperative complications except for ecchymosis development. We conclude that the continuation of antiplatelet medications throughout the perioperative period of elective hernioplasty is safe.
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Affiliation(s)
- David A. Hill
- Department of Surgery, Hofstra Northwell Health at Staten Island University Hospital, Staten Island, New York
| | - Mohamad Sleiman
- Department of Surgery, Hofstra Northwell Health at Staten Island University Hospital, Staten Island, New York
| | - Michael R. Castellano
- Department of Surgery, Hofstra Northwell Health at Staten Island University Hospital, Staten Island, New York
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Kamenova M, Mueller C, Coslovsky M, Guzman R, Mariani L, Soleman J. Low-dose aspirin and burr-hole drainage of chronic subdural hematoma: study protocol for a randomized controlled study. Trials 2019; 20:70. [PMID: 30665464 PMCID: PMC6341728 DOI: 10.1186/s13063-018-3064-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low-dose acetylsalicylic acid (ASA) in patients with chronic subdural hematoma (cSDH) represents a significant neurosurgical challenge. While continuation of ASA during the perioperative phase might increase recurrence and bleeding rates, discontinuation increases the risk of thromboembolic events. The aim of this study is to compare the postoperative recurrence and cardiovascular complication rates of patients undergoing burr-hole trepanation for cSDH with and without discontinuation of ASA. METHODS In this prospective randomized, placebo-controlled, double-blinded study we include all patients undergoing burr-hole drainage of cSDH who are under ASA treatment. The patients are randomized into two groups, one receiving ASA and the other placebo perioperatively. The study primarily seeks to compare the rate of recurrent events under ASA to that under placebo treatment. Secondary objectives are thromboembolic event rate, perioperative blood loss, postoperative anemia, intra- and postoperative blood transfusion rate, and clinical outcome. DISCUSSION To date, there is no evidence-based consensus on how to manage patients undergoing burr-hole drainage for cSDH who are under ASA treatment. Therefore, the decision to maintain or interrupt ASA treatment is based mostly on the surgeons' preference. A randomized placebo-controlled study for this frequent question is urgently needed in order to provide class I evidence for the best possible treatment of this large group of patients. TRIAL REGISTRATION ClinicalTrials.gov: NCT03120182 . Initial Release: 19.04.2017. STUDY PROTOCOL V2_23.02.2017.
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Affiliation(s)
- Maria Kamenova
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland.
| | - Christian Mueller
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 CH, Basel, Switzerland
| | - Michael Coslovsky
- Clinical Trial Unit University Hospital of Basel, Spitalstrasse 12, 4031 CH, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
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Chen CF, Tsai SW, Wu PK, Chen CM, Chen WM. Does continued aspirin mono-therapy lead to a higher bleeding risk after total knee arthroplasty? J Chin Med Assoc 2019; 82:60-65. [PMID: 30839406 DOI: 10.1016/j.jcma.2018.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Evidence about the risk of bleeding and thromboembolism because of aspirin mono-therapy in total knee arthroplasty (TKA) is scant. We wanted to validate the risks of bleeding and thromboembolism with continued aspirin mono-therapy in unilateral and simultaneous bilateral TKA. METHODS We enrolled a series of 1655 patients who underwent unilateral or simultaneous bilateral TKA between December 2010 and December 2012. Drainage amount, postoperative hemoglobin level, change in hemoglobin, calculated blood loss, incidence and the amount of blood transfused, and the proportion of thromboembolic events were compared between patients who were and patients who were not on continued aspirin mono-therapy. RESULTS Calculated blood loss (969.1 ± 324.9 vs. 904.0 ± 315.5 ml), transfusion amounts (1.3 ± 1.5 vs. 1.0 ± 1.3 IU), and percentage of transfused patients (53.0% vs. 40.2%) were higher in unilateral TKA patients on continued aspirin mono-therapy. Outcome parameters and the proportion of DVT between groups were not significantly different. One patient (0.3%) not on aspirin mono-therapy developed a pulmonary embolism, and two others (0.6%) had cerebrovascular events. CONCLUSION Despite the slightly higher risks of bleeding, continuing aspirin mono-therapy during TKA might be safe with low risks of perioperative cerebrovascular, cardiovascular, and venous thromboembolic events.
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Affiliation(s)
- Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Po-Kuei Wu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chao-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Wei-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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Plümer L, Seiffert M, Punke MA, Kersten JF, Blankenberg S, Zöllner C, Petzoldt M. Aspirin Before Elective Surgery-Stop or Continue? DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:473-480. [PMID: 28764836 DOI: 10.3238/arztebl.2017.0473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 10/02/2016] [Accepted: 04/13/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cessation of long-term aspirin treatment before noncardiac surgery can cause adverse cardiac events in patients at risk, particularly in those with previous percutaneous coronary interventions (PCI) with stent implantation. The factors influencing the clinical decision to stop aspirin treatment are currently unknown. METHODS In a single-center, cross-sectional study (retrospective registration: NCT03049566) carried out from February to December 2014, we took a survey among patients scheduled for noncardiac surgery who were under long-term aspirin treatment, and among their treating anesthesiologists using standardized questionnaires on preoperative aspirin use, comorbidities, and risk-benefit assessments. The main objective was to identify factors associated with the decision to stop aspirin treatment. The results of multivariable logistic regressions and intraclass correlations are presented. RESULTS 805 patients were included in the study, and 636 questionnaires were returned (203 of which concerned patients with coronary stents). 46.8% of the patients stopped their long-term aspirin treatment before surgery; 38.7% of these patients stopped it too early (>10 days before surgery) or too late (≤ 3 days before surgery). A prior PCI with stent implantation lowered the probability of aspirin cessation (odds ratio [OR] = 0.47 [0.31; 0.72]; p <0.001). On the other hand, patients were more likely to stop their long-term aspirin treatment if it had already been discontinued once before (OR = 4.58 [3.06; 6.84]; p <0.001), if there was a risk of bleeding into a closed space (OR = 4.54 [2.02; 10.22]; p <0.001), if they did not know why they were supposed to take aspirin (OR = 2.12 [1.05; 4.28]; p = 0.036), or if the preoperative consultation with the anesthesiologist occurred <2 days before surgery (OR = 1.60 [1.08; 2.37]; p = 0.018). Patients often assessed the risks related to aspirin cessation lower than their physicians did. CONCLUSION This study reveals discordance between guideline recommendations and everyday clinical practice in patients with coronary stents. The early integration of cardiologists and anesthesiologists and a more widespread use of stent implant cards could promote adherence to the guidelines.
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Affiliation(s)
- Lili Plümer
- Department of Anesthesiology, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany; Department of General and Interventional Cardiology, University Heart Center Hamburg (UHZ), Hamburg, Germany; Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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81
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Ono K, Hidaka H, Sato M, Nakatsuka H. Preoperative continuation of aspirin administration in patients undergoing major abdominal malignancy surgery. J Anesth 2018; 33:90-95. [PMID: 30483897 DOI: 10.1007/s00540-018-2591-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 11/20/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE In contrast to that in a nonoperative setting, it has been shown that perioperative administration of aspirin did not decrease the rate of death or myocardial infarction but increased major bleeding risk. Since these conflicting results might be due to concurrent use of anticoagulants and a lower thrombotic risk of patients, this cohort study was carried out for patients at a high thrombotic risk without concurrent use of anticoagulants. METHODS Medical records for patients who underwent major abdominal malignancy surgery and who were on a preoperative antiplatelet regimen were reviewed. The patients were divided into two groups according to perioperative antiplatelet management: administration of all preoperative antiplatelet agent-suspended (no aspirin) group and only aspirin administration-continued (aspirin) group. The incidence of symptomatic thromboembolic events, frequency of exogenous blood transfusion within 30 days after surgery and the amount of intraoperative bleeding were compared between the two groups. RESULTS After propensity score matching, 105 patients of each group were matched. The incidence of perioperative thromboembolic events in the no-aspirin group was significantly higher than that in the aspirin group [7/105 (6.7%) vs 0/105 (0%), 95% CI 1.44-∞, P = 0.016]. In contrast, neither the frequency of exogenous transfusion [21.0% vs 11.4%, 95% CI 0.88-4.38 P = 0.110] nor the amount of intraoperative bleeding [median (interquartile range), ml: 230 (70-500) vs 208 (50-500), P = 0.325] was different between the two groups. CONCLUSION Although the sample size is relatively small, our findings suggest that continuation of aspirin administration is likely to reduce the thrombotic risk but unlikely to increase the bleeding risk of patients who undergo major abdominal surgery for malignancy.
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Affiliation(s)
- Kazumi Ono
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan.
| | | | | | - Hideki Nakatsuka
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
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82
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Kawamoto Y, Fujikawa T, Sakamoto Y, Emoto N, Takahashi R, Kawamura Y, Tanaka A. Effect of antithrombic therapy on bleeding complications in patients receiving emergency cholecystectomy for acute cholecystitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:518-526. [DOI: 10.1002/jhbp.588] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Yusuke Kawamoto
- Department of Surgery; Kokura Memorial Hospital; Fukuoka Japan
| | | | - Yusuke Sakamoto
- Department of Surgery; Kokura Memorial Hospital; Fukuoka Japan
| | - Norio Emoto
- Department of Surgery; Kokura Memorial Hospital; Fukuoka Japan
| | - Ryo Takahashi
- Department of Surgery; Kokura Memorial Hospital; Fukuoka Japan
| | | | - Akira Tanaka
- Department of Surgery; Kokura Memorial Hospital; Fukuoka Japan
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83
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Gestion des agents antiplaquettaires pour une procédure invasive programmée. Propositions du Groupe d’intérêt en hémostase périopératoire (GIHP) et du Groupe français d’études sur l’hémostase et la thrombose (GFHT) en collaboration avec la Société française d’anesthésie-réanimation (SFAR). ANESTHÉSIE & RÉANIMATION 2018. [DOI: 10.1016/j.anrea.2018.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Borges JMDM, de Carvalho FO, Gomes IA, Rosa MB, Sousa ACS. Antiplatelet agents in perioperative noncardiac surgeries: to maintain or to suspend? Ther Clin Risk Manag 2018; 14:1887-1895. [PMID: 30323611 PMCID: PMC6178938 DOI: 10.2147/tcrm.s172591] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND When prescribing antiplatelet agents, physicians face the challenge of protecting patients from thromboembolic events without inducing bleeding damage. However, especially in the perioperative period, the use of these medications requires a carefully balanced assessment of their risks and benefits. OBJECTIVE To conduct a systematic review to check whether the antiplatelet agent is to be maintained or suspended in the perioperative period of noncardiac surgeries. SEARCH STRATEGY A comprehensive literature search using Science Direct, Scopus, MEDLINE-PubMed, and Web of Science was undertaken. SELECTION CRITERIA Clinical trials of noncardiac surgeries with patients taking regular anti-platelet therapy, published between 2013 and 2018. RESULTS A total of 1,302 studies were initially identified, with only four meeting the inclusion criteria. The selected studies were conducted in different countries such as, including India (2), Serbia (1), and the USA (1). The age group was similar in all studies, from 61 to 75 years. The most frequent surgery was related to tooth extraction and transurethral resection of bladder cancer. There was a group of patients who used single antiplatelet agents and groups who used single therapy and double therapy. Acetylsalicylic acid was the common drug in all studies. CONCLUSION It was concluded that the clinical trials were classified as good quality and that it was not necessary to suspend antiplatelet therapy prior to surgical procedures such as dental extraction and transurethral resection of bladder cancer. It should be noted that it is necessary to jointly evaluate the type of antiplatelet agent, the thrombotic risk of the patient, and the hemorrhagic risk of the surgical procedure.
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Affiliation(s)
- Juliana Maria Dantas Mendonça Borges
- Nucleus of Post-Graduation in Health Sciences, Federal University of Sergipe, São Cristóvão, Brazil,
- Nucleus of Pharmacy, Tiradentes University, Aracaju, Brazil,
| | | | - Isla Alcântara Gomes
- Nucleus of Post-Graduation in Pharmaceutical Sciences, Federal University of Sergipe, São Cristóvão, Brazil
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Borges JMDM, Almeida PDA, Nascimento MMGD, Barreto Filho JAS, Rosa MB, Sousa ACS. Factors Associated with Inadequate Management of Antiplatelet Agents in Perioperative Period of Non-Cardiac Surgeries. Arq Bras Cardiol 2018; 111:596-604. [PMID: 30281684 PMCID: PMC6199502 DOI: 10.5935/abc.20180162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/23/2018] [Indexed: 12/16/2022] Open
Abstract
Background The current guidelines dispose recommendations to manage antiplatelet agents
in the perioperative period; however, the daily medical practices lack
standardization. Objectives To asses factors associated with inadequate management of antiplatelet agents
in the perioperative period of non-cardiac surgeries. Methods Cross-sectional Study conducted in hospital from October 2014 to October
2016. The study dependent variable was a therapy that did not comply with
the recommendations in the Brazilian Association of Cardiology (SBC)
guidelines. The independent variables included some characteristics, the
people in charge of the management and causes of lack of adherence to those
guidelines. Variables were included in the multivariate model. Analysis was
based on the odds ratio (OR) value and its respective 95% confidence
interval (CI) estimated by means of logistic regression with 5% significance
level. Results The sample was composed of adult patients submitted to non-cardiac surgeries
and who would use acetylsalicylic acid (aspirin) or clopidogrel (n = 161).
The management failed to comply with the recommendations in the guidelines
in 80.75% of the sample. Surgeons had the highest number of noncomplying
orientations (n = 63). After multivariate analysis it was observed that
patients with a higher level of schooling (OR = 0.24; CI95% 0.07-0.78) and
those with a previous episode of acute myocardial infarction (AMI) (OR =
0.18; CI95% 0.04-0.95) had a higher probability of using a therapy complying
with the guidelines. Conclusion Positive association between patients’ schooling level, or those with a
history of previous AMI, with management of the use of aspirin and
clopidogrel in the perioperative period of non-cardiac surgeries. However,
diverging conducts stress the need of having internal protocol defined.
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Affiliation(s)
| | | | | | - José Augusto Soares Barreto Filho
- Universidade Federal de Sergipe, Aracaju, SE - Brasil.,Centro de Ensino e Pesquisa da Fundação São Lucas, Aracaju, SE - Brasil.,Departamento de Medicina da Universidade Federal de Sergipe (UFS), Aracaju, SE - Brasil
| | - Mario Borges Rosa
- Instituto Para Práticas Seguras no Uso de Medicamentos, Belo Horizonte, MG - Brasil
| | - Antonio Carlos Sobral Sousa
- Universidade Federal de Sergipe, Aracaju, SE - Brasil.,Centro de Ensino e Pesquisa da Fundação São Lucas, Aracaju, SE - Brasil.,Departamento de Medicina da Universidade Federal de Sergipe (UFS), Aracaju, SE - Brasil
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86
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Lomivorotov VV, Efremov SM, Abubakirov MN, Belletti A, Karaskov AM. Perioperative Management of Cardiovascular Medications. J Cardiothorac Vasc Anesth 2018; 32:2289-2302. [DOI: 10.1053/j.jvca.2018.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Indexed: 12/28/2022]
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87
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Palmer A, Chen A, Matsumoto T, Murphy M, Price A. Blood management in total knee arthroplasty: state-of-the-art review. J ISAKOS 2018. [DOI: 10.1136/jisakos-2017-000168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Total blood loss from primary total knee arthroplasty may exceed 2 L with greater blood loss during revision procedures. Blood loss and allogeneic transfusion are strongly associated with adverse outcomes from surgery including postoperative mortality, thromboembolic events and infection. Strategies to reduce blood loss and transfusion rates improve patient outcomes and reduce healthcare costs. Interventions are employed preoperatively, intraoperatively and postoperatively. The strongest predictor for allogeneic blood transfusion is preoperative anaemia. Over 35% of patients are anaemic when scheduled for primary and revision knee arthroplasty, defined as haemoglobin <130 g/L for men and women, and the majority of cases are secondary to iron deficiency. Early identification and treatment of anaemia can reduce postoperative transfusions and complications. Anticoagulation must be carefully managed perioperatively to balance the risk of thromboembolic event versus the risk of haemorrhage. Intraoperatively, tranexamic acid reduces blood loss and is recommended for all knee arthroplasty surgery; however, the optimal route, dose or timing of administration remains uncertain. Cell salvage is a valuable adjunct to surgery with significant expected blood loss, such as revision knee arthroplasty. Autologous blood donation is not recommended in routine care, sealants may be beneficial in select cases but further evidence of benefit is required, and the use of a tourniquet remains at the discretion of the surgeon. Postoperatively, restrictive transfusion protocols should be followed with a transfusion threshold haemoglobin of 70 g/L, except in the presence of acute coronary syndrome. Recent studies report no allogeneic transfusions after primary knee arthroplasty surgery after employing blood conservation strategies. The current challenge is to select and integrate different blood conserving interventions to deliver an optimal patient pathway with a multidisciplinary approach.
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88
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Epidural Hematoma Following Interlaminar Epidural Injection in Patient Taking Aspirin. Reg Anesth Pain Med 2018; 43:310-312. [PMID: 29319605 DOI: 10.1097/aap.0000000000000730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We present a case report of a patient who developed an epidural hematoma following an interlaminar epidural steroid injection with no risk factors aside from old age and aspirin use for secondary prevention. CASE REPORT A 79-year-old man developed an epidural hematoma requiring surgical treatment following an uncomplicated interlaminar epidural steroid injection performed for neurogenic claudication. In the periprocedural period, he continued aspirin for secondary prophylaxis following a myocardial infarction. CONCLUSIONS For patients taking aspirin for primary or secondary prophylaxis, the American Society of Regional Anesthesia and Pain Medicine antiplatelet and anticoagulation guidelines for spine and pain procedures recommend a shared assessment and risk stratification when deciding to hold the medication for intermediate-risk neuraxial procedures. Cases such as this serve to highlight the importance of giving careful consideration to medical optimization of a patient even when a low- or intermediate-risk procedure is planned.
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89
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Tamhankar AS, Patil SR, Ahluwalia P, Gautam G. Does Continuation of Low-Dose Aspirin During Robot-Assisted Radical Prostatectomy Compromise Surgical Outcomes? J Endourol 2018; 32:852-858. [DOI: 10.1089/end.2018.0390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Puneet Ahluwalia
- Department of Urooncology, Max Institute of Cancer Care, New Delhi, India
| | - Gagan Gautam
- Department of Urooncology, Max Institute of Cancer Care, New Delhi, India
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Sierra P, Gómez-Luque A, Llau JV, Ferrandis R, Cassinello C, Hidalgo F. Recommendations for perioperative antiplatelet treatment in non-cardiac surgery. Working Group of the Spanish Society of Anaesthesiology-Resuscitation and Pain Therapy, Division of Haemostasis, Transfusion Medicine, and Perioperative Fluid Therapy. Update of the Clinical practice guide 2018. ACTA ACUST UNITED AC 2018; 66:18-36. [PMID: 30166124 DOI: 10.1016/j.redar.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 12/24/2022]
Affiliation(s)
- P Sierra
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Fundación Puigvert (IUNA), Barcelona, España.
| | - A Gómez-Luque
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, España
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Dr. Peset, Universitat de València, Valencia, España
| | - R Ferrandis
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hopital Clínic i Universitari La Fe, Universitat de València, Valencia, España
| | - C Cassinello
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - F Hidalgo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Clínica Universidad de Navarra, Pamplona, España
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Lee JK. Dental management of patients on anti-thrombotic agents. J Korean Assoc Oral Maxillofac Surg 2018; 44:143-150. [PMID: 30181980 PMCID: PMC6117462 DOI: 10.5125/jkaoms.2018.44.4.143] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 07/10/2018] [Indexed: 12/19/2022] Open
Abstract
The number of geriatric patients seeking dental service is ever-rising because of increased life expectancy, also with problem of increased chronic medical conditions. One of them are patients on anti-thrombotic medication. Bleeding complication after minor oral surgery by anti-thrombotic agents is of concerns to dentists on dental management of these patients. Risk and benefit of the anti-thrombotic agents must be weighed before initiating dental procedures, which should be established as a treatment guideline. Purpose of the paper is to optimize the management of the dental patients on anti-thrombotic medication via standardization of treatment protocol of such a patient.
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Affiliation(s)
- Jeong Keun Lee
- Department of Oral and Maxillofacial Surgery and Institute of Oral Health Science, Ajou University Dental Hospital, Ajou University School of Medicine, Suwon, Korea
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92
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Lewis SR, Pritchard MW, Schofield‐Robinson OJ, Alderson P, Smith AF. Continuation versus discontinuation of antiplatelet therapy for bleeding and ischaemic events in adults undergoing non-cardiac surgery. Cochrane Database Syst Rev 2018; 7:CD012584. [PMID: 30019463 PMCID: PMC6513221 DOI: 10.1002/14651858.cd012584.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antiplatelet agents are recommended for people with myocardial infarction and acute coronary syndromes, transient ischaemic attack or stroke, and for those in whom coronary stents have been inserted. People who take antiplatelet agents are at increased risk of adverse events when undergoing non-cardiac surgery because of these indications. However, taking antiplatelet therapy also introduces risk to the person undergoing surgery because the likelihood of bleeding is increased. Discontinuing antiplatelet therapy before surgery might reduce this risk but subsequently it might make thrombotic problems, such as myocardial infarction, more likely. OBJECTIVES To compare the effects of continuation versus discontinuation for at least five days of antiplatelet therapy on the occurrence of bleeding and ischaemic events in adults undergoing non-cardiac surgery under general, spinal or regional anaesthesia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), MEDLINE (1946 to January 2018), and Embase (1974 to January 2018). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA We included randomized controlled trials of adults who were taking single or dual antiplatelet therapy, for at least two weeks, and were scheduled for elective non-cardiac surgery. Included participants had at least one cardiac risk factor. We planned to include quasi-randomized studies.We excluded people scheduled for minor surgeries under local anaesthetic or sedation in which bleeding that required transfusion or additional surgery was unlikely. We included studies which compared perioperative continuation of antiplatelet therapy versus discontinuation of antiplatelet therapy or versus substitution of antiplatelet therapy with a placebo for at least five days before surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias and synthesized findings. Our primary outcomes were: all-cause mortality at longest follow-up (up to six months); all-cause mortality (up to 30 days). Secondary outcomes included: blood loss requiring transfusion of blood products; blood loss requiring further surgical intervention; risk of ischaemic events. We used GRADE to assess the quality of evidence for each outcome MAIN RESULTS: We included five RCTs with 666 randomized adults. We identified three ongoing studies.All study participants were scheduled for elective general surgery (including abdominal, urological, orthopaedic and gynaecological surgery) under general, spinal or regional anaesthesia. Studies compared continuation of single or dual antiplatelet therapy (aspirin or clopidogrel) with discontinuation of therapy for at least five days before surgery.Three studies reported adequate methods of randomization, and two reported methods to conceal allocation. Three studies were placebo-controlled trials and were at low risk of performance bias, and three studies reported adequate methods to blind outcome assessors to group allocation. Attrition was limited in four studies and two studies had reported prospective registration with clinical trial registers and were at low risk of selective outcome reporting bias.We reported mortality at two time points: the longest follow-up reported by study authors up to six months, and time point reported by study authors up to 30 days. Five studies reported mortality up to six months (of which four studies had a longest follow-up at 30 days, and one study at 90 days) and we found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to mortality up to six months (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.34 to 4.27; 659 participants; low-certainty evidence); the absolute effect is three more deaths per 1000 with continuation of antiplatelets (ranging from eight fewer to 40 more). Combining the four studies with a longest follow-up at 30 days alone showed the same effect estimate, and we found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to mortality at 30 days after surgery (RR 1.21, 95% CI 0.34 to 4.27; 616 participants; low-certainty evidence); the absolute effect is three more deaths per 1000 with continuation of antiplatelets (ranging from nine fewer to 42 more).We found that either continuation or discontinuation of antiplatelet therapy probably makes little or no difference in incidences of blood loss requiring transfusion (RR 1.37, 95% CI 0.83 to 2.26; 368 participants; absolute effect of 42 more participants per 1000 requiring transfusion in the continuation group, ranging from 19 fewer to 119 more; four studies; moderate-certainty evidence); and may make little or no difference in incidences of blood loss requiring additional surgery (RR 1.54, 95% CI 0.31 to 7.58; 368 participants; absolute effect of six more participants per 1000 requiring additional surgery in the continuation group, ranging from seven fewer to 71 more; four studies; low-certainty evidence). We found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to incidences of ischaemic events (to include peripheral ischaemia, cerebral infarction, and myocardial infarction) within 30 days of surgery (RR 0.67, 95% CI 0.25 to 1.77; 616 participants; absolute effect of 17 fewer participants per 1000 with an ischaemic event in the continuation group, ranging from 39 fewer to 40 more; four studies; low-certainty evidence).We used the GRADE approach to downgrade evidence for all outcomes owing to limited evidence from few studies. We noted a wide confidence in effect estimates for mortality at the end of follow-up and at 30 days, and for blood loss requiring transfusion which suggested imprecision. We noted visual differences in study results for ischaemic events which suggested inconsistency. AUTHORS' CONCLUSIONS We found low-certainty evidence that either continuation or discontinuation of antiplatelet therapy before non-cardiac surgery may make little or no difference to mortality, bleeding requiring surgical intervention, or ischaemic events. We found moderate-certainty evidence that either continuation or discontinuation of antiplatelet therapy before non-cardiac surgery probably makes little or no difference to bleeding requiring transfusion. Evidence was limited to few studies with few participants, and with few events. The three ongoing studies may alter the conclusions of the review once published and assessed.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Oliver J Schofield‐Robinson
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
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Perioperative aspirin therapy in non-cardiac surgery: A systematic review and meta-analysis of randomized controlled trials. Int J Cardiol 2018; 258:59-67. [DOI: 10.1016/j.ijcard.2017.12.088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 12/09/2017] [Accepted: 12/21/2017] [Indexed: 01/18/2023]
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94
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Bridges KH, Wilson SH. Acute Coronary Artery Thrombus After Tranexamic Acid During Total Shoulder Arthroplasty in a Patient With Coronary Stents: A Case Report. A A Pract 2018; 10:212-214. [DOI: 10.1213/xaa.0000000000000667] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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95
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Gualtierotti R, Parisi M, Ingegnoli F. Perioperative Management of Patients with Inflammatory Rheumatic Diseases Undergoing Major Orthopaedic Surgery: A Practical Overview. Adv Ther 2018; 35:439-456. [PMID: 29556907 PMCID: PMC5910481 DOI: 10.1007/s12325-018-0686-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Indexed: 02/06/2023]
Abstract
Patients with inflammatory rheumatic diseases often need orthopaedic surgery due to joint involvement. Total hip replacement and total knee replacement are frequent surgical procedures in these patients. Due to the complexity of the inflammatory rheumatic diseases, the perioperative management of these patients must envisage a multidisciplinary approach. The frequent association with extraarticular comorbidities must be considered when evaluating perioperative risk of the patient and should guide the clinician in the decision-making process. However, guidelines of different medical societies may vary and are sometimes contradictory. Orthopaedics should collaborate with rheumatologists, anaesthesiologists and, when needed, cardiologists and haematologists with the common aim of minimising perioperative risk in patients with inflammatory rheumatic diseases. The aim of this review is to provide the reader with simple practical recommendations regarding perioperative management of drugs such as disease-modifying anti-rheumatic drugs, corticosteroids, non-steroidal anti-inflammatory drugs and tools for a risk stratification for cardiovascular and thromboembolic risk based on current evidence for patients with inflammatory rheumatic diseases.
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96
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Otto BJ, Terry RS, Lutfi FG, Syed JS, Hamann HC, Gupta M, Bird VG. The Effect of Continued Low Dose Aspirin Therapy in Patients Undergoing Percutaneous Nephrolithotomy. J Urol 2018; 199:748-753. [DOI: 10.1016/j.juro.2017.10.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Brandon J. Otto
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
| | - Russell S. Terry
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
| | - Forat G. Lutfi
- University of Florida College of Medicine, Gainesville, Florida
| | - Jamil S. Syed
- University of Florida College of Medicine, Gainesville, Florida
| | | | - Mohit Gupta
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
| | - Vincent G. Bird
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
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97
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Use of aspirin and bleeding-related complications after hepatic resection. Br J Surg 2018; 105:429-438. [DOI: 10.1002/bjs.10697] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 07/08/2017] [Accepted: 08/22/2017] [Indexed: 12/22/2022]
Abstract
Abstract
Background
The operative risk of hepatectomy under antiplatelet therapy is unknown. This study sought to assess the outcomes of elective hepatectomy performed with or without aspirin continuation in a well balanced matched cohort.
Methods
Data were retrieved from a multicentre prospective observational study. Aspirin and control groups were compared by non-standardized methods and by propensity score (PS) matching analysis. The main outcome was severe (Dindo–Clavien grade IIIa or more) haemorrhage. Other outcomes analysed were intraoperative transfusion, overall haemorrhage, major morbidity, comprehensive complication index (CCI) score, thromboembolic complications, ischaemic complications and mortality.
Results
Before matching, there were 118 patients in the aspirin group and 1685 in the control group. ASA fitness grade, cardiovascular disease, previous history of angina pectoris, angioplasty, diabetes, use of vitamin K antagonists, cirrhosis and type of hepatectomy were significantly different between the groups. After PS matching, 108 patients were included in each group. There were no statistically significant differences between the aspirin and control groups in severe haemorrhage (6·5 versus 5·6 per cent respectively; odds ratio (OR) 1·18, 95 per cent c.i. 0·38 to 3·62), intraoperative transfusion (23·4 versus 23·7 per cent; OR 0·98, 0·51 to 1·87), overall haemorrhage (10·2 versus 12·0 per cent; OR 0·83, 0·35 to 1·94), CCI score (24 versus 28; P = 0·520), major complications (23·1 versus 13·9 per cent; OR 1·82, 0·92 to 3·79) and 90-day mortality (5·6 versus 4·6 per cent; OR 1·21, 0·36 to 4·09).
Conclusion
This observational study suggested that aspirin continuation is not associated with a higher rate of bleeding-related complications after elective hepatic surgery.
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98
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Management of antiplatelet therapy in patients undergoing elective invasive procedures: Proposals from the French Working Group on perioperative hemostasis (GIHP) and the French Study Group on thrombosis and hemostasis (GFHT). In collaboration with the French Society for Anesthesia and Intensive Care (SFAR). Arch Cardiovasc Dis 2018; 111:210-223. [PMID: 29402671 DOI: 10.1016/j.acvd.2017.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 01/02/2023]
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99
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Antiplatelet and anticoagulant agents in vitreoretinal surgery: a prospective multicenter study involving 804 patients. Graefes Arch Clin Exp Ophthalmol 2018; 256:461-467. [DOI: 10.1007/s00417-017-3897-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/08/2017] [Accepted: 12/29/2017] [Indexed: 01/07/2023] Open
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100
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Aspirin therapy discontinuation and intraoperative blood loss in spinal surgery: a systematic review. Neurosurg Rev 2018; 41:1029-1036. [PMID: 29362950 DOI: 10.1007/s10143-018-0945-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/10/2018] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to determine the effect of aspirin therapy discontinuation on intraoperative blood loss in spinal surgery. We searched Medline and Google Scholar 1946 to January 2017 inclusive for case-control studies, cohort studies, and controlled trials reporting intraoperative blood loss during spinal surgery in patients on pre-operative aspirin. Other outcome measures reported in the eligible studies were collected as secondary outcomes. Two reviewers independently screened and extracted data from each study. Five retrospective cohort and two case-control studies were eligible for inclusion. Of the 1173 patients identified, 587 patients were never on aspirin (Ax), 416 patients had aspirin discontinued before surgery (Ad), ranging from 3 to 10 days, and 170 patients had aspirin continued until surgery (Ac). Six out of seven studies reported no statistically significant difference in intraoperative blood loss irrespective of aspirin discontinuation. Meta-analysis was not possible due to high risk of bias. Of the secondary outcome measures, operative time and postoperative complications were most commonly reported. One of six studies evaluating operative time reported a significantly longer operative time in the Ad group compared with the Ac group. The overall risk of postoperative haematoma in Ax, Ad, and Ac groups is 0.2% (n/N = 1/587), 0.2% (n/N = 1/416), and 1.2% (n/N = 2/170), respectively. No study reported a statistically significant difference in postoperative complications. There is no strong evidence demonstrating a difference in intraoperative blood loss, operation time, and postoperative complications, irrespective of aspirin discontinuation. This is, however, based on a limited number of studies and higher-quality research is required to answer this question with a higher degree of confidence.
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