Influence of pre-operative use of serotonergic antidepressants (SADs) on the risk of bleeding in patients undergoing different surgical interventions: a meta-analysis

Management of Depression and Anxiety in Perioperative Medicine

This Clinical Focus Review summarizes contemporary best practices, recent clinically relevant research, and pertinent unanswered questions related to perioperative screening and treatment of anxiety and depression.

Is SSRI use a risk factor for intracranial hemorrhage after craniotomy for tumor resection?

Introduction

Prior studies have identified SSRI use as a risk factor for certain adverse bleeding outcomes. However, the risk of significant bleeding from perioperative SSRI use after brain tumor resection remains largely undetermined. This study evaluates if patients taking SSRIs perioperatively have a higher risk of intracranial hemorrhage (ICH) following elective craniotomy for tumor resection.

Methods

Researchers reviewed electronic medical records of patients age 18 and older, who received elective craniotomy for tumor resection between 2010 and 2019. Data collection included subject demographics and relevant medical history. We compared intracranial hemorrhage rates and risks between perioperative SSRI-use cohorts.

Results

Of 1,061 patients, 796 (75%) did not use SSRIs perioperatively while 265 (25%) used SSRIs perioperatively. Among those using perioperative SSRIs, 8 patients (3.0%) experienced an ICH within 1 week and 11 patients (4.2%) had an ICH within 1 month. Similarly, for those who stopped SSRI use perioperatively, we found 31 patients (3.9%) experienced an ICH within 1 week and 40 patients (5.0%) had an ICH within 1 month. Using logistic regression analysis, the relative risk for perioperative SSRI-use and ICH was statistically non-significant at 0.692 (95% CI: 0.260 - 1.839, p = 0.460).

Conclusions

Based on our results, perioperative SSRI use does not appear to result in an increased risk of bleeding within 1 week or month of craniotomy for tumor resection. These results remained consistent when controlled for several additional bleeding comorbidities and demographics between cohorts.

Case Report: Life-Threatening Fluoxetine-Linked Postoperative Bleeding Informed by Pharmacogenetic Evaluation

BACKGROUND

Selective serotonin reuptake inhibitors (SSRI) are commonly used for the treatment of depression and anxiety. Inhibition of serotonin reuptake in platelets increases bleeding risk in patients taking SSRIs.

CASE

Here, we present the case of a 52-year-old patient who developed severe postsurgical bleeding requiring blood transfusion following panniculectomy.

CONCLUSION

SSRI-induced bleeding is dose-related and strongly influenced by individual variations in drug metabolizing enzymes and transporters. Supplementary file1 (MP4 8441 KB).

Perioperative Anxiety and Depression in Older Adults: Epidemiology and Treatment

The intervals before and after major surgery is a high-risk period for older adults; in this setting, anxiety and depression are common and serious problems. We comprehensively reviewed current evidence on perioperative anxiety and depression in older adults, focusing on epidemiology, impact, correlates, medication risks, and treatment. Principles of perioperative mental healthcare are proposed based on the findings. Prevalence estimates of clinically significant anxiety and depression range from 5% to 45% for anxiety and 6% to 52% for depression, depending on surgical populations and measurement tools. Anxiety and depression may increase risk for surgical complications and reduce patient participation during rehabilitation. Medical comorbidities, pain, insomnia, cognitive impairment, and delirium are common co-occurring problems. Concomitant uses of central nervous system acting medications (benzodiazepines, anticholinergics, and opioids) amplify the risks of delirium and falls. Based on these findings, we propose that anxiety and depression care should be part of perioperative management in older adults; components include education, psychological support, opioid-sparing pain management, sleep management, deprescribing central nervous system active medications, and continuation and optimization of existing antidepressants. More research is needed to test and improve these care strategies.

Evaluation of Bleeding in Orthopedic Surgery With Perioperative Use of Serotonergic Antidepressants

BACKGROUND

The use of serotonergic antidepressants (SADs) is associated with an increase in bleeding, and their exposure during the perioperative period increases the potential bleeding risk in patients undergoing surgical operations.

OBJECTIVE

The purpose of this study was to compare the rates of bleeding between patients on perioperative SADs and those not on SADs in patients undergoing orthopedic surgical procedures.

METHODS

A retrospective cohort study was conducted with patients who were admitted to a single tertiary care county teaching hospital for orthopedic surgery. Outcomes evaluated were requirements of ≥ 2 units of packed red blood cells (PRBCs) and length of hospital stay for those requiring ≥ 2 units of PRBCs.

RESULTS

Of 273 patients, a significantly higher percentage of patients who received SADs required ≥ 2 units of PRBCs (19.3% vs 6.9%; P = 0.0049). Patients who required transfusion had a higher median (interquartile range [IQR]) age (79 [64-84.6] vs 65 [59-75]; P < 0.0001). The risk of requiring ≥ 2 units of PRBCs transfusion was greater for individuals having an anemia comorbidity (odds ratio [OR], 4.55; 95% CI, 1.95-10.62, P = 0.0004). Patients who required ≥ 2 units of PRBCs had a longer median hospital stay than those who did not receive ≥ 2 units of PRBCs (8 [5-10.1] vs 4 [3-5]; P < 0.0001).

CONCLUSION AND RELEVANCE

Receiving SADs in the perioperative period is associated with a higher transfusion requirement in patients undergoing orthopedic surgery. Clinicians should be aware of this increased risk for patients who are taking SADs while undergoing surgical procedures.

[Understanding and assessing the antidepressant drug-associated risk of bleeding]

Antidepressants, in particular selective serotonin reuptake inhibitors (SSRIs), are the most commonly prescribed psychopharmacological drug group. Thus, a precise knowledge of the expected adverse drug reactions is indispensable. The increased risk of bleeding events is well documented, especially in patients treated with SSRIs. However, many other antidepressant drug groups have also been implicated in increasing the risk of bleeding. In the following review, the thrombocytic serotonin system and the respective targets of the different antidepressants are explained. Subsequently, the available literature on bleeding under the respective antidepressant classes or individual substances is presented, using data from meta-analyses whenever possible. In addition to the risk of bleeding in general, individual bleeding entities are also considered, such as gastrointestinal and cerebral hemorrhages. Finally, the effects of other drugs that increase the risk of bleeding (i. e., nonsteroidal anti-inflammatory drugs, platelet aggregation inhibitors and anticoagulants) in combination with antidepressant drugs are discussed. The information presented here is meant to guide practitioner's decision making regarding an appropriate antidepressant pharmacotherapy based on the patient's individual risk constellation.

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.

Selective Serotonin Reuptake Inhibitor (SSRI) Bleeding Risk: Considerations for the Consult-Liaison Psychiatrist

PURPOSE OF REVIEW

To present a clinically oriented review of selective serotonin reuptake inhibitor (SSRI)-related bleeding issues commonly addressed by consult-liaison psychiatrists.

RECENT FINDINGS

Concomitant medical, surgical, or hospital-based conditions exacerbate the risk of SSRI-related bleeding even though a review of the literature suggests it is only marginally elevated. Psychiatrists and other clinicians need to consider these conditions along with antidepressant benefits when answering the question: to start, hold, continue, or change the antidepressant? Where an evidence base is limited, mechanistic understanding may help consult-liaison psychiatrists navigate this terrain and collaborate with other medical specialties on responsible antidepressant management. Most often, the risk is cumulative; data are not directly applicable to complex clinical situations. This review incorporates a hematologic perspective and approach to bleeding risk assessment along with extant data on SSRI-induced bleeding risk ad specific medical conditions.

Perioperative Medication Management in Elective Plastic Surgery Procedures

BACKGROUND

Perioperative medication management is vital to maintain patient safety while under anesthesia, as well as to avoid postoperative complications. Plastic surgeons make daily decisions on whether to ask a patient to stop taking medication before their surgery. These important decisions can affect bleeding risk, wound healing, and interactions with anesthetics, which can range from minor to life-threatening. Current plastic surgery literature lacks a comprehensive review of perioperative medication management, with existing reports focusing on specific procedures and specific medication classes.

METHODS

A PubMed database search was conducted for articles through July 2021. The bibliographies of included studies were also examined for articles not acquired in the initial search queries. The authors included studies on medication usage and perioperative guidance in patients undergoing elective plastic surgery procedures. The authors excluded studies unrelated to plastic surgery and studies where the medications were used as an intervention. Abstracts, animal studies, studies involving the pediatric population, and book chapters were also excluded, as well as articles not published in English.

RESULTS

A total of 801 papers were identified by our search terms. After title and abstract screening, 35 papers were selected for full-text review. After full-text review, 20 papers were selected for inclusion, with an additional 6 papers from cited references added. Of the 26 papers, 6 papers discussed psychotropic drugs, 6 papers discussed medications affecting hemostasis, 4 papers discussed hormone-containing medications, 3 papers discussed antilipid medications, 2 papers discussed antihypertensive medications, 2 papers discussed herbal supplements, 1 paper discussed both psychotropic and herbal supplements, 1 paper discussed medications affecting wound healing, and 1 paper discussed rheumatologic medications. A summary of those recommendations was then compiled together.

CONCLUSIONS

The perioperative medication management in elective plastic surgery procedures remains a complex and multidisciplinary process. It is important to manage these patients in a case-by-case manner and to consult a specialist when necessary. Careful medication reconciliation is essential to decrease the likelihood of adverse outcomes and interactions with perioperative anesthetics.

Association between selective serotonin and serotonin-noradrenaline reuptake inhibitor therapy and hematuria

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are used as first-line treatment for many psychiatric diseases, especially major depressive disorder. However, an important side effect of these drugs is the risk of bleeding due to platelet dysfunction. The aim of this study was to determine the frequency of hematuria in patients using SSRI/SNRIs and to compare with a control group.

METHODS

This study included patients who were followed up and treated with SSRI/SNRI in the psychiatric outpatient clinic of the Antalya Medical Park Hospital between 1 January 2021 and 31 March 2021 and a control group comprising patients who presented to the medical check-up outpatient clinic between the same dates. Complete urinalysis was performed for all patients and the results were compared between the groups.

RESULTS

Each group included 100 patients with a female/male ratio of 1. The mean age was 41.45 ± 13.47 (16-74) years in the study group and 40.51 ± 13.75 (20-70) years in the control group (p = 0.519). Mean duration of SSRI/SNRI use in the study group was 13.35 ± 1.32 (1-64) months. The prevalence of hematuria was 17% in the SSRI/SNRI group and 6% in the control group (p = 0.015). All cases of hematuria were microscopic hematuria.

CONCLUSION

Hematuria is significantly more common in patients receiving SSRI/SNRI treatment. The use of SSRI/SNRI should also be taken into account when investigating the etiology of hematuria.

Preoperative Deprescribing for Medical Optimization of Older Adults Undergoing Surgery: A Systematic Review

OBJECTIVE

To summarize the evidence for preoperative deprescribing and its effect on postoperative outcomes in older adults undergoing surgery.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

All available studies.

METHODS

We searched EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), and PubMed from inception to January 12, 2021. Settings included outpatient settings during the waiting period for surgery (ie, preoperative clinic) through to the preoperative period in the hospital. Participants who were older adults, aged ≥65 years, undergoing planned or emergency surgery with deprescribing or medication-related interventions were included for review.

RESULTS

We identified 3 different methods of deprescribing intervention delivery during the preoperative period: geriatrician-led (n = 2), interdisciplinary team-led (n = 8), and pharmacist-led (n = 6). Outcomes were related to health care utilization, patient outcomes, and medication changes; however, results were difficult to compare because of heterogeneous outcomes within the topics. Overall, results were either positive or neutral.

CONCLUSIONS AND IMPLICATIONS

The evidence for deprescribing during the preoperative period for older adults undergoing surgery is weak because of the heterogeneity of intervention delivery and outcomes, inclusion of nonoperative cases in some studies, and low power. This review highlights the need for future research, which may consider the following: (1) interdisciplinary approach, (2) coordination of deprescribing efforts with primary care provider from the waiting period for surgery up to after hospital discharge, and (3) validated deprescribing criteria such as STOPP/START that is easy to implement. It is important to note that results yielded positive and neutral results, not negative ones, which should reassure clinicians to implement deprescribing for older adults during the surgical period. Additionally, policy initiatives such as integrated electronic medical records or increased reimbursement of deprescribing efforts for primary care providers and/or hospitals should be pursued to prevent adverse postoperative events for this population.

Preoperative Management of Medications for Psychiatric Diseases: Society for Perioperative Assessment and Quality Improvement Consensus Statement

There is a lack of guidelines for preoperative management of psychiatric medications leading to variation in care and the potential for perioperative complications and surgical procedure cancellations on the day of surgery. The Society for Perioperative Assessment and Quality Improvement identified preoperative psychiatric medication management as an area in which consensus could improve patient care. The aim of this consensus statement is to provide recommendations to clinicians regarding preoperative psychiatric medication management. Several categories of drugs were identified including antidepressants, mood stabilizers, anxiolytics, antipsychotics, and attention deficit hyperactivity disorder medications. Literature searches and review of primary and secondary data sources were performed for each medication/medication class. We used a modified Delphi process to develop consensus recommendations for preoperative management of individual medications in each of these drug categories. While most medications should be continued perioperatively to avoid risk of relapse of the psychiatric condition, adjustments may need to be made on a case-by-case basis for certain drugs.

Patients with psychiatric disease: implications for anesthesiologists

PURPOSE OF REVIEW

Psychiatric illness is common in patients presenting for surgery. Overall health and surgical outcomes are adversely affected by the presence of psychiatric comorbidities.

RECENT FINDINGS

As new treatment modalities become available, their perioperative implications need to be evaluated. These implications include drug-drug interactions, hemodynamic effects, bleeding risk, and factors affecting perioperative exacerbation of the underlying psychiatric illness.

SUMMARY

From our review of the recent literature we continue to support the continuation of psychoactive agents in the perioperative period, taking into consideration the effects these agents have on concomitant drug use in the perioperative period; and the risks of withholding them at a high-stress time.

Duloxetine for the reduction of opioid use in elective orthopedic surgery: a systematic review and meta-analysis

Background Duloxetine is currently approved for chronic pain management; however, despite some evidence, its utility in acute, postoperative pain remains unclear Aim of the review This systematic review and meta-analysis is to determine if duloxetine 60 mg given perioperatively, is safe and effective at reducing postoperative opioid consumption and reported pain following elective orthopedic surgery. Method CINAHL, Medline, Cochrane Central Registry for Clinical Trials, Google Scholar, and Clinicaltrials.gov were searched using a predetermined search strategy from inception to January 15, 2019. Covidence.org was used to screen, select, and extract data by two independent reviewers. Individual study bias was assessed using the Cochrane Risk of Bias tool. Opioid consumption data were converted to oral morphine milligram equivalents (MME) and exported to RevMan where meta-analysis was conducted using a DerSimonian and Laird random effects model. Results Six randomized-controlled trials were included in the literature review of postoperative pain and adverse effects. Five studies were utilized for the meta-analysis of postoperative opioid consumption; totaling 314 patients. Postoperative pain analysis showed variable statistical significance with overall lower pain scores with duloxetine. Adverse effects included an increase in insomnia with duloxetine but lower rates of nausea and vomiting. Meta-analysis revealed statistically significant [mean difference (95% CI)] lower total opioid use with duloxetine postoperatively at 24 h [- 31.9 MME (- 54.22 to - 9.6), p = 0.005], 48 h [- 30.90 MME (- 59.66 to - 2.15), p = 0.04] and overall [- 31.68 MME (- 46.62 to - 16.74), p < 0.0001]. Conclusion These results suggest that adding perioperative administration duloxetine 60 mg to a multimodal analgesia regimen within the orthopedic surgery setting significantly lowers total postoperative opioid consumption and reduces pain without significant adverse effects.

Use of serotonin reuptake inhibitors is not associated with increased bleeding after CABG

OBJECTIVES

Selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs) are the most commonly prescribed antidepressants worldwide. Studies suggest that SSRI/SNRIs can increase bleeding following different surgical procedures, including open heart surgery, but results are conflicting. The objective of this study was to analyse their effects on bleeding after coronary artery bypass grafting (CABG).

METHODS

Of 1237 patients that underwent CABG in Iceland in 2007-2016, 97 (7.8%) used SSRIs/SNRIs preoperatively and were compared to a reference group (n = 1140). Bleeding was assessed using 24-h chest-tube output, number of RBC units transfused and reoperation for bleeding. Thirty-day mortality rates and incidence of complications were also compared.

RESULTS

The two groups were comparable with respect to preoperative and operative variables, with the exception of BMI being significantly higher in the SSRI/SNRI group (30.2 vs. 28.3 kg/m², p < 0.001). No significant differences were observed between groups in 24-h chest-tube output [815 (SSRI/SNRI) vs. 877 ml (reference), p = 0.26], number of RBC units transfused (2.2 vs. 2.2, p = 0.99) or the rate of reoperation for bleeding (4.1% vs. 6.0%, p = 0.61). The incidences of complications and 30-day mortality rate were also similar.

CONCLUSIONS

Using three different criteria, preoperative use of SSRIs/SNRIs was not shown to increase bleeding after CABG. Furthermore, short-term complications as well as 30-day mortality rates did not differ from those of controls. Thus, temporary cessation of SSRI/SNRI treatment prior to CABG to decrease the risk of bleeding is unwarranted.

Antidepressants: bleeding or thrombosis?

The contribution of depression to the pathogenesis of cardiovascular disease includes autonomic disturbances, endothelial dysfunction, inflammation, smoking, sedentary lifestyle, carbohydrate craving, and impaired fibrinolysis. There is evidence that serotonergic antidepressants (selective serotonin reuptake inhibitors and serotonin and noradrenaline reuptake inhibitors) restore the fibrinolytic profile. Contrary to common belief, such antidepressants do not affect platelet aggregation induced by adenosine diphosphate or adrenaline but reduce platelet adhesion to collagen. Since platelet collagen receptor glycoprotein VI binds to fibrin, it is possible that fibrinolytic properties of serotonergic antidepressants could impair platelet adhesion to collagen. The profibrinolytic and antiplatelet properties of serotonergic antidepressants help explain the increased risk of gastrointestinal, intracranial, and surgical bleeding in patients using these medications. Studies evaluating the impact of antidepressants on thrombotic and cardiovascular risk have yielded contradictory results. Corroborating the hypothesis that serotonergic antidepressants have profibrinolytic and antiplatelet properties, some authors showed that these medications prevent both cardiovascular and thromboembolic events. Others showed an increased risk of ischemic stroke, cardiac events and thromboembolic disease. Silent brain infarction may present in some elders with depressive symptoms, so it is presumed that antidepressants are prescribed for subclinical stroke patients. Another explanation for the increased risk of cardiovascular and thromboembolic events reported by some authors in individuals taking antidepressants includes antidepressant side effects such as sedation and weight gain and depression comorbidities such as anxiety, obesity and hyperhomocysteinemia. In conclusion, we suggest that serotonergic antidepressants be considered weak anticoagulants. We also suggest that depressed patients with comorbidities increasing the risk of cardiovascular and thromboembolic disease be recommended to follow a balanced diet and engage in physical activity, such as daily walking.

Association of Antidepressant Use With Adverse Health Outcomes: A Systematic Umbrella Review

IMPORTANCE

Antidepressant use is increasing worldwide. Yet, contrasting evidence on the safety of antidepressants is available from meta-analyses, and the credibility of these findings has not been quantified.

OBJECTIVE

To grade the evidence from published meta-analyses of observational studies that assessed the association between antidepressant use or exposure and adverse health outcomes.

DATA SOURCES

PubMed, Scopus, and PsycINFO were searched from database inception to April 5, 2019.

EVIDENCE REVIEW

Only meta-analyses of observational studies with a cohort or case-control study design were eligible. Two independent reviewers recorded the data and assessed the methodological quality of the included meta-analyses. Evidence of association was ranked according to established criteria as follows: convincing, highly suggestive, suggestive, weak, or not significant.

RESULTS

Forty-five meta-analyses (17.9%) from 4471 studies identified and 252 full-text articles scrutinized were selected that described 120 associations, including data from 1012 individual effect size estimates. Seventy-four (61.7%) of the 120 associations were nominally statistically significant at P ≤ .05 using random-effects models. Fifty-two associations (43.4%) had large heterogeneity (I2 > 50%), whereas small-study effects were found for 17 associations (14.2%) and excess significance bias was found for 9 associations (7.5%). Convincing evidence emerged from both main and sensitivity analyses for the association between antidepressant use and risk of suicide attempt or completion among children and adolescents, autism spectrum disorders with antidepressant exposure before and during pregnancy, preterm birth, and low Apgar scores. None of these associations remained supported by convincing evidence after sensitivity analysis, which adjusted for confounding by indication.

CONCLUSIONS AND RELEVANCE

This study's findings suggest that most putative adverse health outcomes associated with antidepressant use may not be supported by convincing evidence, and confounding by indication may alter the few associations with convincing evidence. Antidepressant use appears to be safe for the treatment of psychiatric disorders, but more studies matching for underlying disease are needed to clarify the degree of confounding by indication and other biases. No absolute contraindication to antidepressants emerged from this umbrella review.

The Associations between Central Nervous System Diseases and Haemostatic Disorders

The aim of this review was to examine the relationship between the occurrence of central nervous system (CNS) diseases, the medicines used in their treatment and the blood coagulation process. The paper mainly focuses on the effects of antidepressant and antipsychotic drugs. Special attention has been paid to the influence of drugs on platelets, the vascular endothelium, plasma coagulation and fibrinolysis, regarding coagulation.

Preoperative Management of Medications

Increasingly complex medication regimens for many comorbidities in patients for planned surgical and procedural interventions necessitate detailed preoperative evaluation of the pharmacologic therapy, including the indications, the specific drugs, and dosing amount and interval. The implications of continuing or withholding these agents in the perioperative period need to be elucidated, as well as the risks of interactions and side effects. A comprehensive plan of the management of the therapeutic agents should be devised during the preoperative visit, with input from all relevant specialists, and clearly communicated to the patients in a format that ensures their comprehension and consistent compliance.

Clinical Management of Bleeding Risk With Antidepressants

Objective: This nonsystematic review describes risk of bleeding in treatment with serotonin reuptake inhibitors (SRIs) and provide recommendations for the management of patients at risk of bleeding. Data Sources: Articles were identified by English-language MEDLINE search published prior to June 2018 using the terms SRI, serotonin and noradrenaline reuptake inhibitors, OR antidepressive agents, AND hemorrhage OR stroke. Study Selection and Data Extraction: Meta-analyses were utilized to identify information regarding risk of bleeding with antidepressants. Individual studies were included if they had information regarding bleeding risk with specific SRIs, timing of risk, or risk with medications of interest. Data Synthesis: SRIs increase risk of bleeding by 1.16- to 2.36-fold. The risk is synergistic between SRIs and nonsteroidal anti-inflammatory drugs (NSAIDs; odds ratio [OR] range between studies 3.17-10.9). Acid-reducing medications may mitigate risk of gastrointestinal bleeds in chronic NSAIDs and SRI users (OR range between studies 0.98-1.1). Antidepressants with low or no affinity for the serotonin transporter, such as bupropion or mirtazapine, may be appropriate alternatives for patients at risk of bleeding. Relevance to Patient Care and Clinical Practice: This review includes data regarding bleeding risk for specific antidepressants, concomitant medications, and risk related to duration of SRI use. Considerations and evidence-based recommendations are provided for management of SRI users at high bleeding risk. Conclusions: Clinicians must be aware of the risk of bleeding with SRI use, especially for patients taking NSAIDs. Patient education is prudent for those prescribed NSAIDs and SRIs concurrently.

Do selective serotonin reuptake inhibitors increase the risk of bleeding or mortality following coronary artery bypass graft surgery? A meta-analysis of observational studies

INTRODUCTION

Depressive illness has a high prevalence in patients undergoing coronary artery bypass graft surgery (CABG). The first line treatment for depression are selective serotonin reuptake inhibitors (SSRIs) which inhibit serotonin reuptake in the presynaptic neuronal membrane and uptake by platelets, inhibiting subsequent serotonin-mediated platelet activation. This presents a theoretically increased risk of bleeding and subsequent postoperative mortality. This review aims to investigate the effects of SSRIs on postoperative bleeding, defined as the need for transfusions and re-operation for bleeding, as well as 30-day mortality in patients undergoing CABG.

METHOD

Four hundred and thirty-seven papers were screened with seven meeting the full inclusion criteria.

RESULTS

Meta-analysis demonstrated that SSRI use increased the risk of red blood cell transfusion (odds ratio (OR) = 1.15; 95% confidence interval (CI): 1.06-1.26), but resulted in no difference in the rate of re-operation for bleeding (OR = 1.07; 95% CI: 0.66-1.74). SSRI use had no effect on the rates of platelet (OR = 0.93; 95% CI: 0.79-1.09) or fresh frozen plasma (OR = 0.96; 95% CI: 0.74-1.24) transfusion nor on the mortality rate (OR =1.03; 95 CI: 0.90-1.17).

CONCLUSION

This review demonstrates that SSRIs are largely safe in cardiac surgery as no increase in mortality was observed. However, there is a significantly raised chance of red blood cell transfusion. The heterogeneous nature of the current evidence base highlights the need for further research into SSRIs and whether any effect on patient outcomes in cardiac surgery occurs.

Serotonergic Antidepressants Are Associated with Increased Blood Loss and Risk for Transfusion in Single-Level Lumbar Fusion Surgery

Study Design

Retrospective case-control study.

Purpose

The purpose of this study was to examine the effect of antidepressants on blood loss and transfusion requirements in spinal surgery patients.

Overview of Literature

Several studies have shown an increase in perioperative bleeding in orthopedic surgery patients on antidepressant drug therapy, yet no study has examined the impact of these agents on spinal surgery patients.

Methods

Charts of patients who underwent single-level spinal fusion (posterior lumbar interbody fusion with posterior instrumentation) performed by five fellowship-trained surgeons at a tertiary spine center between 2008 and 2013, were retrospectively reviewed. Exclusion criteria included select medical comorbidities, select drug therapy, and Amercian Society of Anesthesiologists Physical Status Classification score of greater than 2. Serotonergic antidepressants were examined in multivariate analysis to assess their predictive value on estimated blood loss and risk of transfusion.

Results

A total of 235 patients, of which 52% were female, were included. Allogeneic blood was transfused in 7% of patients. The average estimated blood loss was 682±463 mL. Selective serotonin reuptake inhibitors were taken by 10% of all patients. Multivariable regression analysis showed that intake of selective serotonin reuptake inhibitors was a significant predictor for blood loss (average increase of 34%, p=0.015) and for the need of allogeneic blood transfusion (odds ratio, 4.550; p=0.029).

Conclusions

There was a statistically significant association between selective serotonin reuptake inhibitors and both increased blood loss and risk of allogeneic red blood cell transfusion. Surgeons and perioperative providers should take these findings into account when assessing patients' preoperative risk for blood loss and transfusion.

Association of Selective Serotonin Reuptake Inhibitors with Transfusion in Surgical Patients

BACKGROUND

The clinical relevance of chronic exposure to selective serotonin reuptake inhibitors (SSRIs) to transfusion in surgical patients is unclear.

METHODS

We conducted a prospective cohort study involving patients undergoing cardiac, vascular, spinal, and intracranial surgery at 2 academic medical centers. Medication use, demographics, comorbidities, and laboratory values were determined at baseline by patient interview and review of medical records. The primary outcome was transfusion of any hemostatic allogeneic blood product (i.e., fresh frozen plasma, platelets, and/or cryoprecipitate) through postoperative day 2.

RESULTS

The study sample consisted of 767 patients; 364 patients (47.5%) underwent cardiac surgery and the remainder underwent noncardiac surgery. Eighty-eight patients (11.5%) used SSRIs preoperatively. Among cardiac patients, the absolute number of allogeneic transfusions was higher for SSRI users than nonusers (2 [0-6] vs 0 [0-2], median [25%-75%], respectively, P = 0.008), and a similar trend was observed for noncardiac surgery. After adjusting for covariates using ordinal logistic regression, preoperative SSRI use was associated with an approximately 2-fold (odds ratio, 2.2; 95% confidence interval, 1.2-3.98) increase in odds of exposure to allogeneic hemostatic blood products; similar results were observed using propensity score adjustment (odds ratio, 1.85; 95% confidence interval, 1.11-3.07). A significant interaction between SSRI use and surgery type, age, sex, or concurrent antiplatelet therapy was not found; however, heterogeneity in magnitude of effect could not be excluded.

CONCLUSIONS

Preoperative use of SSRIs is associated with increased exposure to allogeneic hemostatic blood products in surgical patients at high risk for perioperative bleeding. Determining whether perioperative continuation or withdrawal of SSRIs produces a net clinical benefit requires randomized controlled trials.

Serotonin Reuptake Inhibitors and Risk of Abnormal Bleeding

Serotonin reuptake inhibitors (SRIs) increase the risk of abnormal bleeding by lowering platelet serotonin and hence the efficiency of platelet-driven hemostasis; by increasing gastric acidity and possibly gastric ulceration; and by other mechanisms. The upper gastrointestinal tract is the commonest site of SRI-related abnormal bleeding; bleeding at this location may be increased by concurrent nonsteroidal anti-inflammatory drug therapy and by treatment with antiplatelet or anticoagulant drugs. Bleeding at this location may be reduced by concurrent administration of acid-suppressing drugs.

Serotonergic antidepressants and increased bleeding risk in patients undergoing breast biopsy

OBJECTIVES

Recent investigations have shown that serotonergic antidepressant (SAd) use may increase the risk of peri-operative bleeding events. Our objective was to evaluate the possibility of a similar association in patients undergoing radiologic breast biopsies.

METHODS

We used data from 3890 patients undergoing 6300 biopsy procedures between January 2011 and October 2014 in the Breast Clinic of McGill University Health Centre, Montreal, Canada. In this case-control study, cases were patients reported to have abnormal bleeding during their biopsy by board-certified radiologists. A control group of nonbleeders was selected using matching according to age and type of biopsy. The correlation between abnormal bleeding and SAd use was assessed using bivariate and multivariate statistical analyses.

RESULTS

There were 97 patients with abnormal bleeding and 137 matched controls; 10 bleeders (cases) were on SAds (7 citalopram, 3 paroxetine) while only 1 nonbleeder (control group) was on a SAd (low-dose sertraline, 25 mg/day). SAds were significantly associated with increased bleeding risk (10.3% versus 0.7%, Fisher's Exact p = 0.001). Moreover, after adjusting for confounding factors (age, type of biopsy, size of biopsy, needle caliber, pathology result and nonsteroidal anti-inflammatory drug use, multivariate logistic regression confirmed that SAds were associated with elevated bleeding risk (16.2, 95% confidence interval 1.87-140.1, p = 0.01).

CONCLUSIONS

This is the first study demonstrating increased bleeding events in breast biopsy patients using SAds. Clinicians should be aware that SAds may be associated with peri-operative bleeding risk, even in relatively minor procedures such as breast biopsies.