Use of aspirin and bleeding-related complications after hepatic resection

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Safety of liver resection in patients receiving antithrombotic therapy: A systematic review of the literature

BACKGROUND

Little is unknown about the effect of chronic antithrombotic therapy (ATT) on bleeding complication during or after hepatectomy. In addition, the safety and effectiveness of chemical prevention for venous thromboembolism (VTE) is still controversial.

AIM

To clarify the effect of ATT on thromboembolism and bleeding after liver resection.

METHODS

Articles published between 2011 and 2020 were searched from Google Scholar and PubMed, and after careful reviewing of all studies, studies concerning ATT and liver resection were included. Data such as study design, type of surgery, type of antithrombotic agents, and surgical outcome were extracted from the studies.

RESULTS

Sixteen published articles, including a total of 8300 patients who underwent hepatectomy, were eligible for inclusion in the current review. All studies regarding patients undergoing chronic ATT showed that hepatectomy can be performed safely, and three studies have also shown the safety and efficacy of preoperative continuation of aspirin. Regarding chemical prevention for VTE, some studies have shown a potentially high risk of bleeding complications in patients undergoing chemical thromboprophylaxis; however, its efficacy against VTE has not been shown statistically, especially among Asian patients.

CONCLUSION

Hepatectomy in patients with chronic ATT can be performed safely without increasing the incidence of bleeding complications, but the safety and effectiveness of chemical thromboprophylaxis against VTE during liver resection is still controversial, especially in the Asian population. Establishing a clear protocol or guideline requires further research using reliable studies with good design.

The Impact of Nonsteroidal Anti-inflammatory Drugs on Older Adult Trauma Patients With Hip Fractures

BACKGROUND

Nonsteroidal anti-inflammatory drug (NSAID) use is frequently recommended for multimodal analgesia to reduce opioid use. We hypothesized that increased NSAID utilization will decrease opioid requirements without leading to significant complications in older adult trauma patients undergoing hip fracture repair.

METHODS

An observational cross-sectional cohort study of 190,057 adult trauma patients over a 6-y period (2008-2014) in the national Premier Healthcare Database was performed. Patients aged 65 or older undergoing femur repair and hip arthroplasty following fractures due to falls were analyzed. Primary outcome was opioid use, and secondary outcomes included transfusion requirements, length of stay (LOS), and organ system dysfunction. Continuous outcomes were analyzed using mixed-effect linear regression models to assess the effect of NSAIDs on the day of surgery. Fixed effects were included for patient and hospital characteristics, comorbidities, co-treatments, and surgery. Random intercepts for each hospital were included to control for clustering. Categorical outcomes were similarly analyzed using mixed-effect logistic regression models.

RESULTS

NSAIDs decreased opioids prescribed (12.01 versus 11.43 morphine milligram equivalents) (odds ratio [OR], -0.23; confidence interval [CI] = -0.41, -0.06) without overall increased bleeding (40.83% versus 43.18%; OR, 1.02; CI = 0.99, 1.05). NSAIDs were associated with reduced LOS (5.61 versus 5.96 d; CI = -0.24, -0.12), intensive care unit admissions (9.73% versus 10.59%; OR, 0.91; CI = 0.86, 0.96), and pulmonary complications (OR, 0.88; CI = 0.83, 0.93). Additionally, there was a 21% prescribing variability based solely on hospital.

CONCLUSIONS

NSAIDs were associated with decreased opioid requirements, hospital LOS, and intensive care unit admissions in older adult trauma patients without overall increase in bleeding. NSAIDs should be considered in multimodal pain regimens, moreover, given prescribing variability guidelines are needed.

LEVEL OF EVIDENCE

Level III, Prognostic.

Impact of preoperative aspirin continuation on bleeding complications during or after liver resection: Propensity score-matched analysis

BACKGROUND

There is insufficient evidence concerning the effect of preoperative continuation of antiplatelet therapy (APT) on intraoperative and postoperative bleeding during liver resection. This study investigated the efficacy and safety of preoperative aspirin continuation on bleeding complications during or after liver resection using propensity score matching (PSM).

METHODS

Between 2005 and 2018, 425 patients who underwent liver resection were enrolled in this study. Patients were divided into two groups; the cAPT group received continued aspirin monotherapy preoperatively (n = 63) and the control group did not (n = 362). Propensity score matching was performed based on the preoperative clinical parameters. Intraoperative and postoperative complications, including bleeding complications, were compared between groups.

RESULTS

After propensity score matching, 126 patients were included in the analysis (cAPT group, n = 63 and control group, n = 63). There were no differences in patients' background characteristics, and intraoperative blood loss was identical between the groups (200 vs 180 mL, P = .54). The frequency of postoperative complications (Clavien-Dindo class 2 or higher, 13/63 [20.6%] vs 13/63 [20.6%], P = 1.00) and postoperative hemorrhagic complication (3/63 [4.8%] vs 3/63 [4.8%], P = 1.00) was also similar between the groups; no difference was observed in the length of postoperative stay (11 days vs 14 days, P = .08).

CONCLUSION

Preoperative continuation of aspirin monotherapy does not affect intraoperative or postoperative bleeding in patients receiving liver resection. Either open or laparoscopic liver resection can be safely performed in patients with continued aspirin therapy.