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Ireland PA, Borruso L, Spencer SKR, Rosen R, Rosen R. Direct oral anticoagulants in skin surgery: a systematic review of their complications and recommendations for perioperative management. Int J Dermatol 2024; 63:413-421. [PMID: 38009338 DOI: 10.1111/ijd.16916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/27/2023] [Accepted: 11/08/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION Many patients undergoing cutaneous surgery are prescribed at least one anticoagulant or antiplatelet agent. With the recent emergence of direct oral anticoagulants (DOACs), there is a deficit of knowledge regarding optimal perioperative management. This review aims to evaluate the evidence and risk surrounding management of DOACs in patients undergoing skin surgeries. METHODS Systematic review of EMBASE, Scopus, and PubMed, with inclusion of studies that detailed perioperative management of DOACs in those undergoing skin surgery. Primary outcome measures were perioperative hemorrhagic and thromboembolic complications. RESULTS Seven thousand seven hundred and forty-one abstracts were identified, with 13 articles meeting inclusion criteria. Two studies investigated complication risk associated with DOAC continuation in skin surgery and found an average rate of hemorrhagic complications of 1.74%. Two studies evaluated complications associated with DOAC cessation prior to skin surgery, with a pooled thromboembolic complication rate of 0.15%. Articles comparing continuation and cessation discovered no decreased risk of bleeding with DOAC cessation prior to surgery (P = 0.93). Seven of the 13 articles compared complications in a control vs a DOAC group undergoing cutaneous procedures. Evidence was conflicting but may have suggested a small increase in bleeding risk in those on DOAC therapy. CONCLUSION Optimal management of anticoagulants perioperatively is difficult because of conflicting information, complicated by advent of novel agents. Risk of hemorrhagic complications with both continuation and interruption of DOAC therapy was low. Perioperative DOAC management can be guided by procedural bleeding and patient clotting risk and can often be continued in minor dermatologic procedures.
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Affiliation(s)
- Patrick A Ireland
- Prince of Wales Hospital, Randwick, NSW, Australia
- University of New South Wales, Randwick, NSW, Australia
| | - Luca Borruso
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Sascha K R Spencer
- Prince of Wales Hospital, Randwick, NSW, Australia
- University of New South Wales, Randwick, NSW, Australia
| | | | - Robert Rosen
- Prince of Wales Hospital, Randwick, NSW, Australia
- Southderm, Kogarah, NSW, Australia
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2
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Richards E, Brown A, Wernham A. Review of infection and bleeding complications in excisional skin surgery. Clin Exp Dermatol 2024; 49:111-120. [PMID: 37798083 DOI: 10.1093/ced/llad339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/07/2023]
Abstract
Skin excision is the primary treatment for skin cancer. Complication rates from skin cancer excision are generally low but rates of complications may vary according to procedural complexity, site and patient factors. It is important that patients are fully informed through the consent process considering individual circumstances, the Montgomery ruling and material risks. The clinician must use an evidence-based approach to the consent process and assessment of risk. We have searched the literature and reviewed the current evidence regarding complications, and their incidence where data were available, following excisional skin surgery. This article aims to enable clinicians to better inform patients during the consent process about associated bleeding and infection risk.
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Affiliation(s)
- Ellen Richards
- Royal Devon University Healthcare NHS Trust, Exeter, Devon, UK
| | - Alistair Brown
- Royal Devon University Healthcare NHS Trust, Exeter, Devon, UK
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Eljilany I, El-Bardissy A, Elewa H. The Dilemma of Peri-Procedural Warfarin Management: A Narrative Review. Clin Appl Thromb Hemost 2021; 27:10760296211012093. [PMID: 34844473 PMCID: PMC8646195 DOI: 10.1177/10760296211012093] [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] [Indexed: 11/16/2022] Open
Abstract
Periprocedural vitamin K antagonist management is a complex process and inherently entails multiple clinical issues. Marked variations have been reported in different aspects of this process. These differences were noted at the clinician and institutional levels owing to the lack of evidence-based data leading to many discrepancies in decision-making. This review aims to address the gap of vitamin K antagonist periprocedural management acknowledged by previously published prescribers’ questionnaires. One of the components of this process is “bridging,” which aims to provide minimal interruption of the anticoagulation period through the use of heparin products. Recent studies showed that bridging is increasing bleeding risk. Secondly, interruption decision relies on the classification of thromboembolism risk which depends on trials that did not include patients with atrial fibrillation. Thirdly, the interruption duration is different among different International normalization ratio levels, which strengthens the difference in the clinical practice of preoperative vitamin K antagonist management. Lastly, the resumption of a vitamin-K antagonist after surgery has many scenarios according to the procedure and patient risk of bleeding. Vitamin-K antagonist periprocedural management is complicated due to individual practice and the lack of strictly implemented institutional standardized protocols to guide, manage and evaluate the process.
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Affiliation(s)
- Islam Eljilany
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Ahmed El-Bardissy
- Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
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Scherer FD, Dressler C, Avila Valles G, Nast A. Komplikationsrisiken im Zusammenhang mit Antithrombotika bei Hautoperationen: Systematischer Review und Metaanalyse. J Dtsch Dermatol Ges 2021; 19:1421-1433. [PMID: 34661363 DOI: 10.1111/ddg.14579_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Fabian David Scherer
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin und dem Berlin Institute of Health, Berlin
| | - Corinna Dressler
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin und dem Berlin Institute of Health, Berlin
| | - Gabriela Avila Valles
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin und dem Berlin Institute of Health, Berlin
| | - Alexander Nast
- Division of Evidence-Based Medicine, Klinik für Dermatologie, Venereologie und Allergologie, Charité - Universitätsmedizin Berlin, Gemeinsame Einrichtung der Freien Universität Berlin, Humboldt-Universität zu Berlin und dem Berlin Institute of Health, Berlin
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6
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Scherer FD, Dressler C, Valles GA, Nast A. Risk of complications due to antithrombotic agents in cutaneous surgery: a systematic review and meta-analysis. J Dtsch Dermatol Ges 2021; 19:1421-1432. [PMID: 34596345 DOI: 10.1111/ddg.14579] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/01/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVES We aimed to determine the risk of complications during cutaneous surgery for the perioperative discontinuation in comparison to the continuation of antithrombotic agents and the bridging of vitamin K antagonists with heparin in comparison to their continuation. METHODS We conducted a systematic review, searching three databases for eligible studies. Methods followed the Cochrane Handbook. We used RoB 2 and ROBINS-I to assess risk of bias. The quality of evidence was judged (GRADE). Fixed-effect meta-analyses were performed. RESULTS Two randomized-controlled trials and 19 prospective cohort studies were included. It is uncertain whether, compared to its discontinuation, continuing acetylsalicylic acid (risk difference (RD) 0.004, 95 % confidence interval (CI) -0.003 to 0.019) perioperatively increases the risk of significant postoperative bleedings (SPB). Compared to its discontinuation, continuing phenprocoumon perioperatively may increase the risk of SPB (RD 0.02, 95 % CI 0.00 to 0.05). Bridging phenprocoumon with heparin perioperatively may increase the risk of SPB when compared to its continuation (RD 0.07, 95 % CI 0.01 to 0.22). No evidence was found regarding bleeding risks for direct oral anticoagulants. CONCLUSIONS No clear indications of major risks of bleedings when continuing antithrombotic agents during minor skin surgeries were identified. However, the quality of evidence was very low.
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Affiliation(s)
- Fabian David Scherer
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Corinna Dressler
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gabriela Avila Valles
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alexander Nast
- Division of Evidence-Based Medicine, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Bonadurer GF, Langeveld AP, Lalla SC, Roenigk RK, Arpey CJ, Otley CC, Baum CL, Trzasko LCO, Brewer JD. Hemorrhagic complications of cutaneous surgery for patients taking antithrombotic therapy: a systematic review and meta-analysis. Arch Dermatol Res 2021; 314:533-540. [PMID: 34132885 DOI: 10.1007/s00403-021-02250-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/12/2021] [Accepted: 05/22/2021] [Indexed: 11/27/2022]
Abstract
Cutaneous operations are generally safe procedures with minimal major risks. Excessive bleeding occasionally occurs, especially for patients taking antithrombotic medications. Conversely, stopping these medications before cutaneous surgery may increase the risk of a thromboembolic event. We aimed to synthesize the evidence regarding the risk of hemorrhage and thromboembolic events for patients undergoing cutaneous surgery while taking antithrombotic therapy. We performed a comprehensive search to identify randomized controlled trials and cohort studies that compared rates of hemorrhage and/or thromboembolic events between patients receiving antithrombotic therapy at cutaneous surgery and patients not receiving it. Odds ratio (OR) and risk difference for complications were calculated with random-effects models. Of 9214 patients taking anticoagulant or antiplatelet medications, 323 (3.5%) had hemorrhagic complications; of 21,696 control patients, 265 (1.2%) had hemorrhagic complications. Patients taking antithrombotic therapy had increased bleeding risk relative to control patients (OR 2.63 [95% CI 1.90-3.63]; P < 0.001) and an increased but less clinically important risk difference (OR 0.02 [95% CI 0.01-0.03]; P < 0.001) with high heterogeneity. No difference was observed in hemorrhage rates among patients whose antithrombotic therapy was stopped vs continued (OR 1.16 [95% CI 0.73-1.83]; P = 0.54). No difference was seen in rates of thromboembolic events among patients taking antithrombotic therapy vs control patients. However, two serious thromboembolic events were noted in a cohort of 59 patients whose antithrombotic therapy was stopped. Because of potentially devastating effects of thromboembolic events, the current accepted practice is indicated for continuation of antithrombotic therapy for patients undergoing cutaneous surgery.
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Affiliation(s)
- George F Bonadurer
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Andrea P Langeveld
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Soogan C Lalla
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,NYC Health and Hospitals, Central Office Division, 55 Water St, New York, NY, 10041, USA
| | - Randall K Roenigk
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher J Arpey
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Clark C Otley
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christian L Baum
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Jerry D Brewer
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Lushchak O, Piskovatska V, Strilbytska O, Kindrat I, Stefanyshyn N, Koliada A, Bubalo V, Storey KB, Vaiserman A. Aspirin as a Potential Geroprotector: Experimental Data and Clinical Evidence. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1286:145-161. [PMID: 33725352 DOI: 10.1007/978-3-030-55035-6_11] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aging is a biological process with effects at the molecular, cellular, tissue, organ, system, and organismal levels and is characterized by decline in physical function and higher risks of age-related diseases. The use of anti-aging drugs for disease prevention has become a high priority for science and is a new biomedicine trend. Geroprotectors are compounds which slow aging and increase lifespan of the organism in question. The common painkiller aspirin, a member of the non-steroidal anti-inflammatory drug (NSAID) family, is one of the potential geroprotective agents. Aspirin is often used in treatment of mild to moderate pain. It has anti-inflammatory and anti-pyretic properties and acts as an inhibitor of cyclooxygenase which results in inhibition of prostaglandin. Acetylsalicylic acid as an active compound of aspirin also inhibits platelet aggregation and is used in the prevention of arterial and venous thrombosis. Aspirin has shown life-extending effects in numerous model organisms. This chapter reviews the evidence for clinical efficacy of aspirin including cardiovascular disease prevention, anti-cancer effects, and improvement of cognitive function. However, there are some limitations of these therapies, including the risk of excessive bleeding. We have also summarized numerous experimental and analytical data that support health and longevity benefits of aspirin treatment by affecting pro-longevity pathways.
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Affiliation(s)
- Oleh Lushchak
- Department of Biochemistry and Biotechnology, Vasyl Stefanyk Precarpathian National University, Ivano-Frankivsk, Ukraine.
| | - Veronika Piskovatska
- Clinic for Heart Surgery, University clinic of Martin Luther University, Halle, Germany
| | - Olha Strilbytska
- Department of Biochemistry and Biotechnology, Vasyl Stefanyk Precarpathian National University, Ivano-Frankivsk, Ukraine
| | | | - Nadya Stefanyshyn
- Department of Biochemistry and Biotechnology, Vasyl Stefanyk Precarpathian National University, Ivano-Frankivsk, Ukraine
| | - Alexander Koliada
- Laboratory of Epigenetics, D.F. Chebotarev Institute of Gerontology, NAMS, Kyiv, Ukraine
| | - Volodymyr Bubalo
- Laboratory of Experimental Toxicology and Mutagenesis L.I. Medved's Research Center of Preventive Toxicology, Food and Chemical Safety, MHU, Kyiv, Ukraine
| | | | - Alexander Vaiserman
- Laboratory of Epigenetics, D.F. Chebotarev Institute of Gerontology, NAMS, Kyiv, Ukraine
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Siscos SM, Neill BC, Singh AH, Hocker TLH. Thrombotic complications with interruption of direct oral anticoagulants in dermatologic surgery. J Am Acad Dermatol 2020; 84:425-431. [PMID: 33045293 DOI: 10.1016/j.jaad.2020.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 09/24/2020] [Accepted: 10/05/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs), such as apixaban, rivaroxaban, and dabigatran, are increasingly being used to provide prophylaxis and treatment for arterial and venous thromboembolism. Multiple procedural subspecialties have implemented guidelines detailing time frames for perioperative DOAC interruption; however, the impact of perioperative DOAC interruption in patients undergoing dermatologic surgery is currently unknown, and evidence-based guidelines are lacking. OBJECTIVE To assess the 30-day postoperative rate of thrombotic complications (ischemic stroke, transient ischemic attack, systemic embolism, deep vein thrombosis [DVT] and pulmonary embolism) in patients with nonvalvular atrial fibrillation (AF) or a history of DVT who underwent perioperative DOAC interruption during dermatologic surgery. METHODS A retrospective medical record review was performed of all patients with AF or a history of DVT who underwent perioperative DOAC interruption during dermatologic surgery at Advanced Dermatologic Surgery and the University of Kansas Medical Center between January 1, 2016, and August 31, 2020. RESULTS Among 806 operations, comprising 750 Mohs micrographic operations (93.1%) and 56 excisions (6.9%), 1 patient (0.14% of patients with AF) sustained a transient ischemic attack and 2 patients (0.25% of all patients) sustained minor bleeding complications during the 30-day postoperative period. CONCLUSION Perioperative DOAC interruption appears to be safe and efficacious in dermatologic surgery.
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Affiliation(s)
- Spyros M Siscos
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas.
| | - Brett C Neill
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas
| | | | - Thomas L H Hocker
- Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas; Advanced Dermatologic Surgery, Overland Park, Kansas
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Abstract
Decisions surrounding periprocedural anticoagulation management must balance thromboembolic and procedural bleed risk. The interruption of both warfarin and DOACs requires consideration of anticoagulant pharmacokinetics, procedural bleed risk and patient characteristics. There is a diminishing role for periprocedural bridging LMWH overall and no role for bridging LMWH for the procedural interruption of DOACs. A clinical approach to perioperative DOAC management based on operative bleeding risk and renal function is safe and effective, and at present, is preferred over preprocedural DOAC levels testing. Clear communication of the anticoagulation interruption plan to both the patient and the patient's care team is essential.
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Affiliation(s)
- Joseph R Shaw
- Ottawa Blood Disease Center, Division of Hematology, The Ottawa Hospital, Box 206, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada. https://twitter.com/JRand083
| | - Eric Kaplovitch
- Department of Medicine, University Health Network, The University of Toronto, 585 University Avenue, Norman Urquhart Building, 7th Floor, Room 739, Toronto, Ontario M5G 2N2, Canada. https://twitter.com/kaplovitch
| | - James Douketis
- Department of Medicine, Division of General Internal Medicine, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario L4N 4A6, Canada; Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario L4N 4A6, Canada.
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Chen AF, He X, Nirwan RS, Sridhar J, Kuriyan AE. Perioperative Management of Anticoagulants in Ocular Surgeries. Int Ophthalmol Clin 2020; 60:3-15. [PMID: 32576719 PMCID: PMC7334869 DOI: 10.1097/iio.0000000000000316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Use of anticoagulant therapy has increased in patients presenting for ophthalmic surgery over the past decade. The decision of whether or not to discontinue anticoagulant medications prior to ophthalmic surgeries is nuanced and ultimately based on multiple factors including the type of surgery and the patient’s comorbidities and risk profile. In the setting of cataract surgery, no increased risk of bleeding with anticoagulation was observed in a large prospective study, which suggests that anticoagulation should not be interrupted for the average-risk patient on anticoagulation. In other types of ophthalmic surgery, expert opinion and studies are divided on the perioperative management of anticoagulant therapy. Preoperative thromboembolic risk stratification, intraoperative techniques to minimize bleeding, and postoperative management are also reviewed to generate more comprehensive recommendations on ophthalmic perioperative management of anticoagulation.
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Affiliation(s)
- Alexander F. Chen
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
| | - Xu He
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
| | - Rajinder S. Nirwan
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
| | | | - Ajay E. Kuriyan
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
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12
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Forsyth MG, Clarkson DJ, O’Boyle CP. A systematic review of the risk of postoperative bleeding with perioperative non-steroidal anti-inflammatory drugs (NSAIDs) in plastic surgery. EUROPEAN JOURNAL OF PLASTIC SURGERY 2018. [DOI: 10.1007/s00238-018-1410-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Isted A, Cooper L, Colville RJ. Bleeding on the cutting edge: A systematic review of anticoagulant and antiplatelet continuation in minor cutaneous surgery. J Plast Reconstr Aesthet Surg 2018; 71:455-467. [DOI: 10.1016/j.bjps.2017.11.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/24/2017] [Accepted: 11/10/2017] [Indexed: 11/16/2022]
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14
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Feng L, Li Y, Li J, Yu B. Oral anticoagulation continuation compared with heparin bridging therapy among high risk patients undergoing implantation of cardiac rhythm devices. Thromb Haemost 2017; 108:1124-31. [DOI: 10.1160/th12-07-0498] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 09/16/2012] [Indexed: 01/29/2023]
Abstract
SummaryIt was the objective of this study to systematically compare the effects of oral anticoagulation (OAC) with heparin bridging therapy among patients at high risk for thromboembolism undergoing implantation of cardiac rhythm devices. A systematic search of PubMed/MEDLINE, Ovid and Elsevier, and the Cochrane Library databases was conducted. Six trials that met our inclusion criteria were identified and included in the present study. The endpoints of this meta-analysis included pocket haematoma, severe haematoma requiring drainage/revision, thromboembolic events, and length of hospital stay. Data were expressed as odds ratios (ORs) and 95% confidence interval (CIs). There was a statistically significant reduction of pocket haematoma (OR 0.29, 95% CI: 0.17 to 0.49, p<0.00001) and haematoma drainage/revision (OR 0.15, 95%CI: 0.04 to 0.54, p=0.004), respectively, in the OAC continuation group versus the heparin bridging group. We did not detect any statistically sig- nificant differences of thromboembolic events (OR 0.48, 95%CI: 0.07 to 3.54, p=0.48) in the two groups. There was a trend that patients in bridging group had longer hospital stays. In conclusion, OAC continu- ation had a better risk-beneficial ratio and shorter length of hospital stay, and was more convenient to implement compared with heparin bridging therapy among patients at high risk for thromboembolism undergoing implantation of cardiac rhythm devices.
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Kumar NB, Allen K, Bell H. Perioperative Herbal Supplement Use in Cancer Patients: Potential Implications and Recommendations for Presurgical Screening. Cancer Control 2017; 12:149-57. [PMID: 16062162 DOI: 10.1177/107327480501200302] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Products made from botanicals that are used to maintain or improve health are known as herbal supplements, botanicals, or phytomedicines. Many herbs have a long history of use and claimed health benefits. However, many herbal supplements and botanicals have potent pharmacologic activity that can contribute to adverse effects and drug interactions. The use of herbal supplements by cancer patients in the perioperative period is common and consistent with the substantial increase in the use of alternative medical therapies. METHODS We reviewed the literature to examine the constituents, safety, pharmacokinetics, and pharmacodynamics of those herbal supplements that are predominantly used by cancer patients. RESULTS Different supplements possess antiplatelet activity, adversely interact with corticosteroids and central nervous system depressant drugs, have gastrointestinal manifestations, produce hepatotoxicity and nephrotoxicity, and produce additive effects when used with opioid analgesics. CONCLUSIONS With the increasing use of herbal supplements by cancer patients, surgical staff need to screen patients pre-surgically for use of these supplements. Clinical practice guidelines are needed for screening and prevention of herbal supplement usage to prevent potential adverse events that may arise from herbal medications taken alone or combined with conventional therapies during the perioperative period.
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Affiliation(s)
- Nagi B Kumar
- Department of Nutrition, H. Lee Moffitt Cancer Center & Research Institute, University of South Florida College of Medicine, Tampa, Florida 33612, USA.
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Kreicher KL, Bordeaux JS. Addressing Practice Gaps in Cutaneous Surgery: Advances in Diagnosis and Treatment. JAMA FACIAL PLAST SU 2017; 19:147-154. [PMID: 27768177 DOI: 10.1001/jamafacial.2016.1269] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Importance Cutaneous surgery is performed by otolaryngologists, plastic surgeons, oculoplastic surgeons, dermatologic surgeons, and some primary care physicians. Practice gaps exist among cutaneous surgeons, as do differences in how different physicians approach preoperative, intraoperative, and postoperative decision-making. Objective To present the newest and best evidence to close common practice gaps in cutaneous surgery. Evidence Review We performed a detailed search of peer-reviewed publications that were identified through a search of PubMed/MEDLINE (January 1, 2000, through June 30, 2016) using the literature search terms "cutaneous surgery," "Mohs micrographic surgery," "plastic surgery," in combination with "safety," "cost," "anesthesia," "anti-coagulation," "bleeding," "pain," "analgesia," "anxiety," or "infection," among others. Bibliographies from these references, as well as meta-analyses, were also reviewed. Findings A total of 73 peer-reviewed studies, including randomized clinical trials, were selected to support the conclusions of the article. Levels of evidence were analyzed for selected studies using recommendations from the American Association of Plastic Surgeons based on guidelines from the Oxford Centre for Evidence-Based Medicine. Large cutaneous surgical resections can be done effectively and safely, taking steps to assure patient comfort under local anesthesia. Medically necessary anticoagulant and antiplatelet medication should be continued during cutaneous surgery. In preparation for surgery, patient anxiety and pain must be addressed. Music and anxiolytics limit anxiety, prevent cardiovascular compromise, and improve patient satisfaction. Cutaneous surgeons and support staff should carefully consider the dose and injection angle of local anesthetic. Postoperative opioids and topical antibiotics might cause harm to patients and should be avoided. Acetaminophen and ibuprofen provide adequate pain control with fewer adverse effects than opioid medications. Conclusions and Relevance Clinicians performing cutaneous surgery should understand the importance of patient safety and comfort, as guided by recent evidence.
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Affiliation(s)
- Kathryn L Kreicher
- University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jeremy S Bordeaux
- University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
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Sun Y, Wang Y, Li L, Zhang Z, Wang N, Wu D. Continuous Aspirin Use Does Not Increase Bleeding Risk of Split-Thickness Skin Transplantation Repair to Chronic Wounds. J Cutan Med Surg 2017; 21:316-319. [PMID: 28301951 DOI: 10.1177/1203475417697652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Discontinuation of aspirin therapy before cutaneous surgery may cause serious complications. OBJECTIVES The aim of this prospective study was to evaluate the bleeding risk of split-thickness skin transplantation repair to chronic wounds in patients on aspirin therapy. METHODS A total of 97 patients who underwent split-thickness skin transplantation surgery of chronic wounds during a 2-year period were enrolled. They were categorized on the basis of aspirin therapies. The primary outcome was postoperative bleeding and bleeding complications. Univariate analysis was performed to examine the association between aspirin and bleeding complications. Among the 26 patients taking aspirin continuously in group A, there were 5 bleeding complications (19.23%). Among the 55 nonusers in group B, there were 10 bleeding complications (18.18%). Among the 16 discontinuous patients in group C, there were 3 bleeding complications (18.75%). No statistical differences were found among the groups ( P = .956). Univariate analysis showed that continuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.933; 95% confidence interval, 0.283-3.074; P = .910 in the aspirin and control groups) and that discontinuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.963; 95% confidence interval, 0.230-4.025; P = .959 in the aspirin and control groups; odds ratio, 0.969; 95% confidence interval, 0.198-4.752; P = .969 in the aspirin and discontinuous groups). CONCLUSIONS Continuous aspirin use does not produce an additional bleeding risk in patients who undergo split-thickness skin transplantation repair of chronic wounds.
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Affiliation(s)
- Yanwei Sun
- 1 Department of Burns & Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China.,2 Department of Burns & Plastic Surgery, Central Hospital of Zibo, Zibo, Shandong Province, China
| | - Yibing Wang
- 1 Department of Burns & Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Liang Li
- 2 Department of Burns & Plastic Surgery, Central Hospital of Zibo, Zibo, Shandong Province, China
| | - Zheng Zhang
- 2 Department of Burns & Plastic Surgery, Central Hospital of Zibo, Zibo, Shandong Province, China
| | - Ning Wang
- 2 Department of Burns & Plastic Surgery, Central Hospital of Zibo, Zibo, Shandong Province, China
| | - Dan Wu
- 2 Department of Burns & Plastic Surgery, Central Hospital of Zibo, Zibo, Shandong Province, China
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Hunt WTN, McGrath EJ. Dermatological postoperative patient information leaflets: is it time for more uniformity? Clin Exp Dermatol 2015; 40:747-52. [PMID: 26271961 DOI: 10.1111/ced.12701] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Patient information leaflets (PILs) are an important source of information for patients postoperatively. There are currently no nationally agreed standards by dermatologists for postoperative advice following skin surgery. AIM To assess the common themes and areas of variation in advice given in PILs after skin surgery across all National Health Service (NHS) hospitals in England and Wales. METHODS All acute trusts in England (n = 159) and local health boards in Wales (n = 7) were requested to provide their postoperative dermatological PILs for general sutured wound care or excision biopsy. Eight preselected parameters were assessed: minimum dressing duration, duration of pressing on a bleeding wound, postoperative analgesia, explanation of infection signs, application of petroleum jelly, scarring, whom to contact if there is a problem, and the recommended postoperative time for abstaining from active exercise. RESULTS PILs were received from 137 different dermatology departments belonging to 127/166 (76.5%) organisations across England and Wales. Of these, 102 PILs gave a specific duration for dressings: 45/102 (44.1%) advised a minimum of 48 h, but 28/102 (27.5%) recommended leaving dressings in place until suture removal. Regarding duration of pressing on a bleeding wound, 117 PILs gave advice, with the most common recommendation being 15 min (30/117, 25.6%), followed closely by 10 min (26/117, 22.2%). Of the 137 PILs received, 125 gave advice regarding postoperative analgesia, with paracetamol alone being the most common recommendation (24/125, 19.2%). For the remaining parameters, 111/137 (81.0%) PILs described ≥ 2 signs of infection, 42/137 (30.7%) recommended the application of petroleum jelly, 65/137 (47.4%) mentioned scarring, 137/137 (100%) highlighted whom to contact if there were postoperative problems and 87/137 (63.5%) PILs gave advice regarding postoperative abstinence from active exercise. CONCLUSIONS The advice given in dermatology postoperative PILs across England and Wales is highly variable. A nationally agreed template or set of postoperative advice should be considered to improve consistency.
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Affiliation(s)
- W T N Hunt
- Dermatology Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - E J McGrath
- Dermatology Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
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Shipkov H, Irthum C, Seguin P, Mojallal A, Braye F. Evaluation of the risk of post-operative bleeding complications in skin cancer surgery without interruption of anticoagulant/antithrombotic medication: A prospective cohort study. J Plast Surg Hand Surg 2015; 49:242-6. [PMID: 25835043 DOI: 10.3109/2000656x.2015.1029935] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Previous reports showed lack of consensus concerning interruption of anticoagulant/antithrombotic (AC/AT) treatment before skin cancer surgery. AIM The aim of this study was to evaluate the risk of postoperative bleeding in patients on AC/AT treatment undergoing skin cancer surgery without interruption of this treatment. METHOD This prospective cohort study included 271 consecutive patients divided into two groups - patients without and patients with AC/AT therapy. Inclusion criteria were skin cancer (basal-cell carcinoma, squamous-cell carcinoma, or malignant melanoma). Exclusion criteria were patients undergoing regional lymph node dissection or sentinel lymph node biopsy. Postoperative bleeding complications taken into consideration were those evaluated as moderate or severe and requiring some form of surgical or non-surgical hemostasis on an outpatient or inpatient basis. RESULTS There were 47 patients in the AC/AT group and 224 in the control group (mean age = 76.6 and 68 years, respectively), with almost equal distribution of tumours in both groups. There were 34.1% of patients on AT, 55% on AC treatment, and 10.6% on mixed treatment (AC+AT or AT+AT). Postoperative bleeding complications did not show a statistically significant difference between the two groups (p = 0.063). CONCLUSION Skin cancer surgery can be safely performed without discontinuation of AC/AT treatment, since the risk of postoperative bleeding is statistically insignificant.
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Affiliation(s)
- Hristo Shipkov
- Department of Plastic, Reconstructive and Aesthetic Surgery, Croix Rousse Hospital , Lyon , France
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Sporbeck B, Bechara FG, Häfner HM, Koenen W, Kolk A, Koscielny J, Meissner M, Pokrywka A, Schirmer S, Strömer K, Löser C, Nast A. S3-Leitlinie zum Umgang mit Antikoagulation bei Operationen an der Haut. J Dtsch Dermatol Ges 2015. [DOI: 10.1111/ddg.12576_suppl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Birte Sporbeck
- Division of Evidence Based Medicine, Charité - Universitätsmedizin Berlin
| | | | | | | | - Andreas Kolk
- Klinik und Poliklinik für Mund-, Kiefer- und Gesichtschirurgie, Klinikum rechts der Isar, Technische Universität München
| | - Jürgen Koscielny
- Institut für Transfusionsmedizin, Charité - Universitätsmedizin Berlin
| | - Markus Meissner
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt
| | - Anna Pokrywka
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin
| | - Steffen Schirmer
- Klinik für Plastische, Wiederherstellungs- und Ästhetische Chirurgie - Handchirurgie, Klinikum Bielefeld Mitte
| | - Klaus Strömer
- Niedergelassene Dermatologe, Gemeinschaftspraxis Dr. Strömer / Deden, Mönchengladbach
| | - Christoph Löser
- Hautklinik, Hauttumorzentrum, Klinikum der Stadt Ludwigshafen am Rhein gGmbH
| | - Alexander Nast
- Division of Evidence Based Medicine, Charité - Universitätsmedizin Berlin
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Sporbeck B, Georges Bechara F, Häfner HM, Koenen W, Kolk A, Koscielny J, Meissner M, Pokrywka A, Schirmer S, Strömer K, Löser C, Nast A. S3 guidelines for the management of anticoagulation in cutaneous surgery. J Dtsch Dermatol Ges 2015; 13:346-56. [PMID: 25819254 DOI: 10.1111/ddg.12576] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND An increasing number of patients are being treated with anticoagulants and platelet inhibitors. Whenever surgical procedures of the skin are required, questions arise regarding the perioperative management of anticoagulation. METHODS Development of S3 guidelines following the requirements of the Association of Scientific Medical Societies, systematic literature search and analysis, use of GRADE methodology, structured consensus conference using a nominal group process. RESULTS During cutaneous surgery, treatment with acetylsalicylic acid (ASA) should be continued if medically necessary. In procedures with a higher risk of bleeding and a positive bleeding history, INR should be determined preoperatively. Surgical procedures of the skin with a higher risk of bleeding should not be performed if the INR is above therapeutic range. Bridging from vitamin K antagonists (VKA) to heparin should not be performed just because of the surgery of the skin. As to direct-acting oral anticoagulants, the last dose should be taken 24 h preoperatively. CONCLUSIONS The recommendations issued by the German guidelines group are mostly in line with recommendations provided by other guidelines. The American ìChest-Guidelineì recommends continuing VKAs and acetylsalicylic acid during minor dermatologic procedures. In their guidelines, the German College of General Practitioners and Family Physicians considers an INR of 2 to be adequate in surgical procedures on the skin.
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Affiliation(s)
- Birte Sporbeck
- Division of Evidence Based Medicine, Charité - Universitätsmedizin Berlin
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Novel oral anticoagulants: what dermatologists need to know. J Am Acad Dermatol 2015; 72:535-40. [PMID: 25582538 DOI: 10.1016/j.jaad.2014.11.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/09/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022]
Abstract
The development of novel oral anticoagulants provides clinicians and patients a welcome alternative to the challenges of warfarin therapy. Dermatologists must be aware of the potential impact of novel oral anticoagulants on their surgical and medical practice. This review provides a concise summary of the novel oral anticoagulants for dermatologists with particular emphasis on: (1) the pharmacokinetic properties of these drugs and how they differ from warfarin, (2) suggested management during cutaneous surgery, (3) adverse drug interactions with commonly prescribed medications in dermatology, and (4) potential use within dermatology for treatment of disorders of cutaneous thrombosis.
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Jarjis RD, Jørgensen L, Finnerup K, Birk-Sørensen L. Complications in skin grafts when continuing antithrombotic therapy prior to cutaneous surgery requiring skin grafting: A systematic review. J Plast Surg Hand Surg 2014; 49:129-34. [PMID: 25289685 DOI: 10.3109/2000656x.2014.967254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The risk of postoperative bleeding and wound healing complications in skin grafts among anticoagulated patients undergoing cutaneous surgery has not been firmly established. The objective was to examine the literature and assess the risk of postoperative bleeding or wound healing complications in skin grafts among anticoagulated patients, compared with patients who discontinue or patients who are not receiving antithrombotic therapy prior to cutaneous surgery requiring skin grafting. A systematic review examining the effect of antithrombotic therapy on cutaneous surgery was performed according to the PRISMA-guidelines. PubMed and Embase databases were primarily searched for relevant literature in the period from the start date of each database to 2014. A total of eight studies representing 443 patients met criteria for inclusion. No randomised controlled trials were found; the included studies were of prospective and retrospective design. Most of the reviewed studies suggest that the use of antithrombotic therapy can increase the risk of bleeding complications in skin grafts. These complications are only wound threatening and not life threatening. Therefore, this is of concern mostly in terms of hemostasis by the surgeon and good pressure dressings. Care should be taken when operating on anticoagulated patients undergoing cutaneous surgery requiring skin grafting. However, graft failure is rare and, given the risk of thrombotic events, the reviewed studies recommend continuing all medically necessary antithrombotic therapy. The limitations of this study are the small sample sizes and the level of evidence; hence, more research is needed to substantiate these preliminary findings.
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Affiliation(s)
- Reem D Jarjis
- Department of Plastic & Reconstructive Surgery, Aalborg University Hospital , Aalborg , Denmark
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Abstract
Dermatosurgery has become an integral and essential component of current dermatology practice. No surgery can be totally risk free, only the level of risk varies. Patient safety has to be ensured by following standard protocols and taking appropriate precautions to prevent complications and mishaps. Mismatch between patient's expectations and outcome can lead to litigation. A dermatosurgeon should take care of his legal safety by obtaining informed consent and meticulously documenting and preserving medical records. Importance of communication and maintaining of fiduciary relationship with the patient cannot be overemphasized.
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Affiliation(s)
- K H Satyanarayana Rao
- Consultant Dermatologist, Central Government Health Scheme Polyclinic, Bangalore and Member, Indian Association of Dermatologists, Venereologists and Leprologists Dermatosurgery Task Force, Bangalore, Karnataka, India
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Nast A, Ernst H, Rosumeck S, Erdmann R, Jacobs A, Sporbeck B. Risk of complications due to anticoagulation during dermatosurgical procedures: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2014; 28:1603-9. [PMID: 25132203 DOI: 10.1111/jdv.12611] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 05/26/2014] [Indexed: 01/22/2023]
Abstract
Background Management of anticoagulation and anti-platelet drugs during cutaneous surgery is still a challenge for many dermatologists and standards of care with respect to stopping, continuing or bridging vary widely. Methods We performed a systematic review (Medline, Cochrane Library, until August 27th, 2013) of studies assessing the risk of complications due to anticoagulation during cutaneous surgery. Primary outcomes were mild-moderate and severe postsurgical bleeding. The secondary outcomes were excessive and uncontrollable intraoperative bleeding and other postsurgical complications as wound dehiscence, erythema, wound infection. Results 1.287 publications were identified and 10 studies were included into the review. The frequencies of bleeding in the control groups in general were low (about 1%). In patients on aspirin, increased risks were seen neither with respect to mild-moderate postoperative bleeding (RR 1.1, CI 0.5-2.3), nor with respect to severe bleeding (RR 0.9, CI 0.2-4.6). The studies with patients on warfarin showed a risk for mild-moderate bleeding that was three times as high as in controls (RR 3.2, CI 1.4-7.1) and for severe bleeding that was 15 times higher (RR 14.8, CI 2.7-80.4). In general the study sizes were small and the methodological quality low. Conclusion The risk of bleeding due to a medication with aspirin seems to be negligible. With warfarin, the risk is increased; an exact estimate of the risk increase is difficult to give, because of the lack of sufficient high quality studies. A two-fold increase appears likely, the 15-fold increase is most likely due to statistical reasons arising from the rareness of the event in the small number of included patients. Stopping, bridging or continuing a medication should always be an individual decision. In accordance with guidelines from internal medicine for most patients it will be recommendable to continue with the medication.
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Affiliation(s)
- A Nast
- Division of Evidence-Based Medicine (dEBM), Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Bavozet F, Mahé I. [VKA anticoagulant bridging for an invasive procedure or planned surgery: A survey of practices in general practitioners]. Presse Med 2014; 43:e221-31. [PMID: 24785139 DOI: 10.1016/j.lpm.2013.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 12/02/2013] [Accepted: 12/11/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In 2011, 1.7 % of the French population was receiving a Vitamine K Antagonist (VKA) anticoagulant therapy. VKA related adverse events are the first cause for iatrogenic events in France. Anticoagulant bridging period is a period at both increased risk for thromboembolic and bleeding events. The Haute Autorité de santé (HAS) established in 2008 recommendations in order to help physicians to manage anticoagulant therapy in case of invasive procedure or surgery, according to the procedure and the indication of VKA. PRIMARY AIM To assess anticoagulant treatment management by general physicians when an invasive procedure or a planned surgery in a patient receiving long-term VKA Data have been compared to HAS recommendations. METHODS A descriptive transversal survey performed in general physicians à at the conference held in Nice in 2012. An anonymous questionnaire was built, including questions about clinical situations and knowledge questions. RESULTS Eighty-eight out of 200 submitted questionnaires have been completed (44%). Overall, 4.5% of questioned physicians have managed fully in accordance with HAS recommendations the 6 clinical situations cliniques about patients receiving long-term VKA for atrial fibrillation, recurrent pulmonary embolism, and mechanical valvular prothesis. Bridgings using Low Molecular Weight Heparins have been excessively proposed by asked physicians and bridging prescription was most of the time wrong (9% correct). Otherwise, no physician has answered correctly all theoretical questions; patients at high and low thromboembolic risk are not well distinguished; 64% of physicians think they are influenced by specialists who have prescribed the procedure. DISCUSSION Few physicians manage VKA therapy in accordance with HAS recommendations in case of invasive procedure. There are many hypotheses: bad knowledge of recommendations, overestimation of the thromboembolic risk related to VKA stopping during the period of the invasive procedure, underestimation of the risk of bleeding related to the bridging period of time; influence of specialists. We propose a decisional algorithm in order to improve the implementation of HAS recommendations in usual care.
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Affiliation(s)
- Florent Bavozet
- AP-HP, université Paris 7, Paris Diderot, Sorbonne Paris Cité, EA Recherche clinique, coordonnée ville-hôpital, Méthodologies et Société (REMES), hôpital Louis-Mourier, service de médecine interne, 92700 Colombes, France
| | - Isabelle Mahé
- AP-HP, université Paris 7, Paris Diderot, Sorbonne Paris Cité, EA Recherche clinique, coordonnée ville-hôpital, Méthodologies et Société (REMES), hôpital Louis-Mourier, service de médecine interne, 92700 Colombes, France.
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Harbottle M, Telfer M, Hunjan PS, Knepil GJ, Singh RP. Bleeding complications in cutaneous surgery for patients on warfarin who have skin cancer of the head and neck. Br J Oral Maxillofac Surg 2014; 52:523-6. [PMID: 24792859 DOI: 10.1016/j.bjoms.2014.03.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 03/18/2014] [Indexed: 10/25/2022]
Abstract
Many patients who have operations on the head and neck for skin cancer also take warfarin to prevent thromboembolic events, and there is still debate about whether treatment should be continued, adjusted, or temporarily stopped. The main concern is to balance the risk of haemorrhagic and thromboembolic events. In this prospective controlled study we compared bleeding complications in operations for skin cancer of the head and neck between 86 patients who took warfarin (100 tumours) and 87 (100 tumours) who did not. Surgeons of different grades did the operations under the guidance of the same consultant. All those on warfarin had above normal international normalised ratios (INRs) (mean (SD) 2.5 (0.51), mode 2.6, range 1.1-4.0). In the warfarin group 8% of excisions had a bleeding complication compared with 9% in the control group. One patient in each group suffered a severe bleed that required a return to theatre. The difference in tendency to bleed between the groups was not significant (p=0.30), and the site and type of reconstruction did not influence the risk of bleeding significantly. This study shows that patients on warfarin who are within the normal therapeutic range, can be operated on safely for skin cancer by all levels of trained staff.
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Affiliation(s)
- Matthew Harbottle
- Department of Oral and Maxillofacial Surgery, York Teaching Hospitals Foundation Trust, Wigginton Road, York YO31 8HE, United Kingdom.
| | - Martin Telfer
- Department of Oral and Maxillofacial Surgery, York Teaching Hospitals Foundation Trust, Wigginton Road, York YO31 8HE, United Kingdom.
| | - Premneaq Singh Hunjan
- Department of Oral and Maxillofacial Surgery, York Teaching Hospitals Foundation Trust, Wigginton Road, York YO31 8HE, United Kingdom.
| | - Greg J Knepil
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester Royal Infirmary, Great Western Road, Gloucester GL1 3NN, United Kingdom.
| | - Rabindra Pratap Singh
- Department of Oral and Maxillofacial Surgery, York Teaching Hospitals Foundation Trust, Wigginton Road, York YO31 8HE, United Kingdom.
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Causey HE, Hodulik KL. Management of Warfarin in Patients Desiring Tattoo Placement. J Pharm Technol 2013. [DOI: 10.1177/8755122513500908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To provide a review of the primary literature regarding recommendations for management of chronic warfarin therapy during tattoo placement. Data Sources: PubMed and IDIS were searched (up to May 2013) using the search terms vitamin K antagonists, warfarin, anticoagulation, tattoo, tattoo placement, cutaneous procedure, and cutaneous surgery. Study Selection and Data Extraction: No trials including subjects on warfarin undergoing tattoo placement were identified. Clinical trials were included if they were published in English and included subjects on chronic warfarin therapy undergoing cutaneous procedures. Tattoo placement is similar to cutaneous procedures as skin is marked by puncturing into the dermal layer and inserting pigments, and minor bleeding is possible. Thus, recommendations of anticoagulation management for cutaneous procedures were evaluated. Data Synthesis: Eleven articles evaluating warfarin continuation around cutaneous surgery met selection criteria. Ten articles evaluated hemorrhagic complications, and 1 article evaluated thrombotic risk of perioperative anticoagulation discontinuation. In patients continuing warfarin compared to discontinuing warfarin, perioperative bleeding rate was statistically higher in 4 studies, trended higher in 3 studies, and was comparable in 3 studies. Thrombotic risk was increased when warfarin was withheld perioperatively from patients on chronic therapy. Conclusions: Trials evaluating chronic warfarin therapy in patients undergoing cutaneous surgery have conflicting recommendations for warfarin continuation through surgery. At a minimum, international normalized ratio should be evaluated prior to procedures with delay if the international normalized ratio is elevated. Thrombotic risk should be fully assessed prior to holding warfarin in patients on chronic warfarin therapy. Trials evaluating management of chronic warfarin therapy in the setting of tattoo placement are needed.
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Eichhorn W, Barsukov E, Al-Dam A, Gröbe A, Smeets R, Eichhorn M, Heiland M, Kluwe L, Blessmann M. Postoperative bleeding risk for cutaneous surgery in the head and neck region with continued phenprocoumon therapy. J Craniomaxillofac Surg 2013; 42:608-11. [PMID: 24103463 DOI: 10.1016/j.jcms.2013.08.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 07/08/2013] [Accepted: 08/28/2013] [Indexed: 11/26/2022] Open
Abstract
In a total of 171 surgical procedures for lesions in the head and neck region in patients in whom phenprocoumon therapy was not stopped, 16 (9%) postoperative bleeding events were observed over a follow-up period of two weeks. Local measures were sufficient in all cases except one severe case where blood transfusion was needed and anticoagulant treatment was stopped for 7 days. The bleeding risk was significantly higher for the surgical procedures of the nose than those in other areas (21% versus 6%, P = 0.014), but was not influenced by the international normalized ratio (INR) of blood coagulation, size, site and type of the lesion, surgical procedure, and sex and age of the patients. The bleeding rate in patients not on any anticoagulation therapy was significantly lower (6/211 = 3%). Across both groups, just over 80% of the bleeding episodes were within the first two days (55% on the same day and 32% on the next day) of the surgery. No bleeding was recorded after 5 days. Our data suggest that cutaneous surgery in the head and neck region can be safely performed with continued phenprocoumon therapy in most cases in an INR range of 1.3-3.4, but rarely severe bleeding does occur and can be managed with a close-contact follow-up and with 24-h on call services during the first two days postoperatively.
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Affiliation(s)
- Wolfgang Eichhorn
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Max Heiland), University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany; Department of Oral and Maxillofacial Surgery (Head: PD Dr. Dr. Wolfgang Eichhorn), General Hospital Balingen, Balingen, Germany
| | - Evgeny Barsukov
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Max Heiland), University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Ahmed Al-Dam
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Max Heiland), University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Alexander Gröbe
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Max Heiland), University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Ralf Smeets
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Max Heiland), University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Marc Eichhorn
- Department of Oral and Maxillofacial Surgery (Head: PD Dr. Dr. Wolfgang Eichhorn), General Hospital Balingen, Balingen, Germany
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Max Heiland), University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany.
| | - Lan Kluwe
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Max Heiland), University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany; Department of Neurology (Head: Prof. Dr. Christian Gerloff), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marco Blessmann
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Max Heiland), University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
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McKenzie JL, Douglas G, Bazargan A. Perioperative management of anticoagulation in elective surgery. ANZ J Surg 2013; 83:814-20. [PMID: 23601136 DOI: 10.1111/ans.12171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2013] [Indexed: 12/01/2022]
Abstract
Surgeons commonly need to treat patients receiving anticoagulant and anti-platelet therapy. This requires risk assessment and management to balance minimization of bleeding complications and avoidance of further ischaemic or thrombotic events. This review considers the evidence available to guide management of patients on anti-platelet and anticoagulant therapy, including some of the new classes of anti-platelets and anticoagulants which clinicians may be less familiar with.
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Affiliation(s)
- Jo-Lyn McKenzie
- Department of Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
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Abstract
Abstract
The periprocedural management of patients receiving long-term oral anticoagulant therapy remains a common but difficult clinical problem, with a lack of high-quality evidence to inform best practices. It is a patient's thromboembolic risk that drives the need for an aggressive periprocedural strategy, including the use of heparin bridging therapy, to minimize time off anticoagulant therapy, while the procedural bleed risk determines how and when postprocedural anticoagulant therapy should be resumed. Warfarin should be continued in patients undergoing selected minor procedures, whereas in major procedures that necessitate warfarin interruption, heparin bridging therapy should be considered in patients at high thromboembolic risk and in a minority of patients at moderate risk. Periprocedural data with the novel oral anticoagulants, such as dabigatran, rivaroxaban, and apixaban, are emerging, but their relatively short half-life, rapid onset of action, and predictable pharmacokinetics should simplify periprocedural use. This review aims to provide a practical, clinician-focused approach to periprocedural anticoagulant management.
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Abstract
The ability to recognize, manage, and, most importantly, prevent hemorrhagic complications is critical to performing dermatologic procedures that have safe and high quality outcomes. This article reviews the preoperative, intraoperative, and postoperative factors and patient dynamics that are central to preventing such an adverse outcome. Specifically, the role that anticoagulants and anti-platelet agents, hypertension, and other medical conditions play in the development of postoperative hemorrhage are discussed. In addition, this article provides practical guidelines on managing bleeding during and after surgery.
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33
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Kallas PG. Assessing and Managing Neurovascular, Neurodegenerative, and Neuromuscular Disorders. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Kose R, Sogut O, Demir T, Koruk I. Hemostatic Efficacy of Folkloric Medicinal Plant Extract in a Rat Skin Bleeding Model. Dermatol Surg 2012; 38:760-6. [DOI: 10.1111/j.1524-4725.2011.02288.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S-e350S. [PMID: 22315266 DOI: 10.1378/chest.11-2298] [Citation(s) in RCA: 1034] [Impact Index Per Article: 86.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure. METHODS The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement. RESULTS In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C). CONCLUSIONS Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Michael Mayr
- Medical Outpatient Department, University Hospital Basel, Basel, Switzerland
| | - Amir K Jaffer
- Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, OH
| | - Andrew S Dunn
- Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Regina Kunz
- Academy of Swiss Insurance Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland.
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Douketis JD. Perioperative management of patients receiving anticoagulant or antiplatelet therapy: a clinician-oriented and practical approach. Hosp Pract (1995) 2012; 39:41-54. [PMID: 22056822 DOI: 10.3810/hp.2011.10.921] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The management of patients who are receiving warfarin, aspirin, clopidogrel, or combinations of these drugs and require their interruption because of an elective surgical or other invasive procedure is a common and sometimes challenging clinical problem. For the practicing clinician, there are 2 key issues for perioperative anticoagulant management: 1) having an approach to stratify patients according to their risk for thromboembolism when warfarin or antiplatelet drug therapy is interrupted, and also having an approach to stratify patients according to the risk of bleeding associated with the surgery or procedure; and 2) determining which patients may require bridging anticoagulation and, if required, how to administer bridging, typically with a low-molecular-weight heparin, before and after surgery in a manner that minimizes the risk for bleeding. The overall goal is to minimize patients' risk for thromboembolism and bleeding throughout the perioperative period. The objective of this article is to provide an evidence-based but practical approach relating to these 2 key issues in a manner than can be applied to everyday clinical practice.
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Assaad B, Sesi VK, Figari R, Schultz L, Thummala N, Rehman M, Chandok A, Silverman A, Silver B. Antithrombotic management of stroke patients before colonoscopy. J Stroke Cerebrovasc Dis 2012; 22:733-6. [PMID: 22244711 DOI: 10.1016/j.jstrokecerebrovasdis.2011.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 12/12/2011] [Accepted: 12/17/2011] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Uncertainty exists regarding the management of antithrombotic medications in ischemic stroke and transient ischemic attack (TIA) patients around the time of colonoscopy. We sought to evaluate whether there was a difference in adverse events among patients who continued medications and those who had temporary discontinuation. METHODS Using a hospital administrative database, electronic charts of patients with a diagnostic code for stroke or TIA and a procedural code for colonoscopy were reviewed. Information collected included baseline demographics, medical history, and antithrombotic medications. Outcome measures were stroke (ischemic and hemorrhagic), myocardial infarction, venous thromboembolism, and major systemic bleeding (i.e., requiring transfusion) up to 4 weeks after the procedure among patients who had medications continued versus temporarily discontinued. RESULTS One hundred seventy-seven patients met inclusion criteria. Antithrombotic medication was temporarily discontinued in 42 patients and continued in 135 patients. Comparing patients who had medications held to those who had medications continued, stroke occurred in 1 (2.4%) versus 0 (0%; P = .237) patients; myocardial infarction in no patients in either group; venous thromboembolism in 0 (0%) versus 1 (0.7%; P > .99) patients; and major system bleeding in 2 (4.8%) versus 4 (3.0%; P = .628) patients. CONCLUSIONS In this retrospective analysis, there was no significant difference in the occurrence of stroke, myocardial infarction, venous thromboembolism, and major bleeding between patients who had medications continued around the time of colonoscopy versus those who had temporary discontinuation. A prospective, randomized controlled study is warranted to further elucidate this issue.
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Affiliation(s)
- Basel Assaad
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan, USA
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38
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Garcia Araque HF, Acosta DO. Antiagregación plaquetaria en cirugía no cardíaca. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2011. [DOI: 10.5554/rca.v39i4.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Bordeaux JS, Martires KJ, Goldberg D, Pattee SF, Fu P, Maloney ME. Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. J Am Acad Dermatol 2011; 65:576-583. [PMID: 21782278 DOI: 10.1016/j.jaad.2011.02.012] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Revised: 01/12/2011] [Accepted: 02/23/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few prospective studies have evaluated the safety of dermatologic surgery. OBJECTIVE We sought to determine rates of bleeding, infection, flap and graft necrosis, and dehiscence in outpatient dermatologic surgery, and to examine their relationship to type of repair, anatomic location of repair, antibiotic use, antiplatelet use, or anticoagulant use. METHODS Patients presenting to University of Massachusetts Medical School Dermatology Clinic for surgery during a 15-month period were prospectively entered. Medications, procedures, and complications were recorded. RESULTS Of the 1911 patients, 38% were on one anticoagulant or antiplatelet medication, and 8.0% were on two or more. Risk of hemorrhage was 0.89%. Complex repair (odds ratio [OR] = 5.80), graft repair (OR = 7.58), flap repair (OR = 11.93), and partial repair (OR = 43.13) were more likely to result in bleeding than intermediate repair. Patients on both clopidogrel and warfarin were 40 times more likely to have bleeding complications than all others (P = .03). Risk of infection was 1.3%, but was greater than 3% on the genitalia, scalp, back, and leg. Partial flap necrosis occurred in 1.7% of flaps, and partial graft necrosis occurred in 8.6% of grafts. Partial graft necrosis occurred in 20% of grafts on the scalp and 10% of grafts on the nose. All complications resolved without sequelae. LIMITATIONS The study was limited to one academic dermatology practice. CONCLUSION The rate of complications in dermatologic surgery is low, even when multiple oral anticoagulant and antiplatelet medications are continued, and prophylactic antibiotics are not used. Closure type and use of warfarin or clopidogrel increase bleeding risk. However, these medications should be continued to avoid adverse thrombotic events.
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Affiliation(s)
- Jeremy S Bordeaux
- Department of Dermatology, University Hospitals Case Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | | | - Dori Goldberg
- Division of Dermatology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sean F Pattee
- Dermatology Associates of Wisconsin, Manitowoc, Wisconsin
| | - Pingfu Fu
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mary E Maloney
- Division of Dermatology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
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Bell AD, Roussin A, Cartier R, Chan WS, Douketis JD, Gupta A, Kraw ME, Lindsay TF, Love MP, Pannu N, Rabasa-Lhoret R, Shuaib A, Teal P, Théroux P, Turpie AG, Welsh RC, Tanguay JF. The use of antiplatelet therapy in the outpatient setting: Canadian Cardiovascular Society Guidelines Executive Summary. Can J Cardiol 2011; 27:208-21. [PMID: 21459270 DOI: 10.1016/j.cjca.2010.12.033] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 12/14/2010] [Accepted: 12/15/2010] [Indexed: 12/16/2022] Open
Abstract
Antiplatelet agents are a cornerstone of therapy for patients with atherosclerotic vascular disease. There is presently a lack of comprehensive guidelines focusing on the use of antiplatelet drugs in patients currently manifesting or at elevated risk of cardiovascular disease. The Canadian Antiplatelet Therapy Guidelines Committee reviewed existing disease-based guidelines and subsequently published literature and used expert opinion and review to develop guidelines on the use of antiplatelet therapy in the outpatient setting. This Executive Summary provides an abbreviated version of the principal recommendations. Antiplatelet therapy appears to be generally underused, perhaps in part because of a lack of clear, evidence-based guidance. Here, we provide specific guidelines for secondary prevention in patients discharged from hospital after acute coronary syndromes, percutaneous coronary intervention, or coronary artery bypass grafting; patients with a history of transient cerebral ischemic events or strokes; and patients with peripheral arterial disease. Issues related to primary prevention are also addressed, in addition to special clinical contexts such as diabetes, heart failure, chronic kidney disease, pregnancy or lactation, and perioperative management. Recommendations are provided regarding pharmacologic interactions that may occur during combination therapy with warfarin, clopidogrel, and proton-pump inhibitors, or aspirin and nonsteroidal anti-inflammatory drugs, as well as for the management of bleeding complications. The complete guidelines document is published as a supplementary issue of the Canadian Journal of Cardiology and is available at http://www.ccs.ca/.
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Affiliation(s)
- Alan D Bell
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Perioperative management of patients who are receiving warfarin therapy: an evidence-based and practical approach. Blood 2011; 117:5044-9. [DOI: 10.1182/blood-2011-02-329979] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Bell AD, Roussin A, Cartier R, Chan WS, Douketis JD, Gupta A, Kraw ME, Lindsay TF, Love MP, Pannu N, Rabasa-Lhoret R, Shuaib A, Teal P, Théroux P, Turpie AG, Welsh RC, Tanguay JF. The Use of Antiplatelet Therapy in the Outpatient Setting: Canadian Cardiovascular Society Guidelines. Can J Cardiol 2011; 27 Suppl A:S1-59. [DOI: 10.1016/j.cjca.2010.12.015] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 12/09/2010] [Accepted: 12/10/2010] [Indexed: 01/17/2023] Open
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Chu MB, Turner RB, Kriegel DA. Patients with drug-eluting stents and management of their anticoagulant therapy in cutaneous surgery. J Am Acad Dermatol 2011; 64:553-8. [DOI: 10.1016/j.jaad.2009.11.691] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2009] [Revised: 11/18/2009] [Accepted: 11/29/2009] [Indexed: 11/25/2022]
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Lip GYH, Durrani OM, Roldan V, Lip PL, Marin F, Reuser TQ. Peri-operative management of ophthalmic patients taking antithrombotic therapy. Int J Clin Pract 2011; 65:361-71. [PMID: 21314873 DOI: 10.1111/j.1742-1241.2010.02538.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Increasing number of patients presenting for ophthalmic surgery are using oral anti-coagulant and anti-platelet therapy. The current practice of discontinuing these drugs preoperatively because of a presumed increased risk of bleeding may not be evidence-based and could pose a significant risk to the patient's health. To provide an evidence-based review on the peri-operative management of ophthalmic patients who are taking anti-thrombotic therapy. In addition, we briefly discuss the underlying conditions that necessitate the use of these drugs as well as management of the operative field in anti-coagulated patients. A semi-systematic review of literature was performed. The databases searched included MEDLINE, EMBASE, database of abstracts of reviews of effects (DARE), Cochrane controlled trial register and Cochrane systematic reviews. In addition, the bibliographies of the included papers were also scanned for evidence. The published data suggests that aspirin did not appear to increase the risk of serious postoperative bleeding in any type of ophthalmic surgery. Topical, sub-tenon, peri-bulbar and retrobulbar anaesthesia appear to be safe in patients on anti-thrombotic (warfarin and aspirin) therapy. Warfarin does not increase the risk of significant bleeding in most types of ophthalmic surgery when the INR was within the therapeutic range. Current evidence supports the continued use of aspirin and with some exceptions, warfarin in the peri-operative period. The risk of thrombosis-related complications on disruption of anticoagulation may be higher than the risk of significant bleeding by continuing its use for most types of ophthalmic surgery.
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Affiliation(s)
- G Y H Lip
- Haemostasis Thrombosis and Vascular Biology Unit, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK.
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Václavík J, Táborský M. Antiplatelet therapy in the perioperative period. Eur J Intern Med 2011; 22:26-31. [PMID: 21238889 DOI: 10.1016/j.ejim.2010.10.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 10/01/2010] [Accepted: 10/25/2010] [Indexed: 12/22/2022]
Abstract
The current practice of withdrawing aspirin 7-10 days preoperatively may be dangerous in certain groups of patients. The risk of cardiovascular events increases 3-fold after aspirin withdrawal. The average time between aspirin withdrawal and the manifestation of acute coronary syndrome is 8 to 11 days. The withdrawal of clopidogrel earlier than 4-6 weeks after bare metal stent implantation or less than 12 months after drug-eluting stent implantation is very risky and poses a high risk of stent thrombosis and high perioperative mortality. Continuing aspirin perioperatively leads to a 1.5-fold increase in perioperative bleeding complications but it does not lead to a higher severity of bleeding complications or higher mortality. The article analyzes current European and American guidelines for perioperative antiplatelet treatment and suggests an algorithm based on the guidelines to help make clinical decisions.
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Affiliation(s)
- Jan Václavík
- Department of Internal Medicine I-Cardiology, University Hospital Olomouc and Palacký University Faculty of Medicine, I. P. Pavlova 6, 775 20, Olomouc, Czech Republic.
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Critical Overview on the Benefits and Harms of Aspirin. Pharmaceuticals (Basel) 2010; 3:1491-1506. [PMID: 27713314 PMCID: PMC4033993 DOI: 10.3390/ph3051491] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 04/30/2010] [Accepted: 05/07/2010] [Indexed: 12/21/2022] Open
Abstract
Aspirin is widely used internationally for a variety of indications, with the most prominent one being that of cardiovascular disease. However, aspirin has also been proposed as a treatment option in a diverse range of conditions such as diabetes mellitus, cancer prevention, and obstetrics. In our overview, we critically appraise the current evidence from recent systematic reviews and meta-analyses covering the benefits of aspirin across these conditions. We also look at evidence that some patients may not derive benefit due to the concept of aspirin resistance. Aspirin is also associated with the potential for significant harm, principally from haemorrhagic adverse events. We critically appraise the threat of haemorrhagic complications, and weigh up these risks against that of any potential benefit.
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Kovac Z, Kovac M, Mitic G, Antonijevic N. The oncology treatment of patients who use oral anticoagulants is connected with high risk of bleeding complications. J Thromb Thrombolysis 2010; 30:210-4. [DOI: 10.1007/s11239-010-0438-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Surgical complications. Dermatol Surg 2009. [DOI: 10.1016/b978-0-7020-3049-9.00017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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50
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Bassas P, Bartralot R, García-Patos V. Anticoagulation and Antiplatelet Therapy in Dermatology. ACTAS DERMO-SIFILIOGRAFICAS 2009. [DOI: 10.1016/s1578-2190(09)70004-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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