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Houben AM, Crepy M, Senard M, Bonhomme V, Tchana-Sato V, Hans G. Preoperative continuation of aspirin before isolated heart valve surgery and postoperative bleeding and transfusion: a single-center retrospective study. Acta Chir Belg 2024; 124:274-280. [PMID: 38146908 DOI: 10.1080/00015458.2023.2298097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/18/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND The risks and benefits of preoperative aspirin continuation in patients undergoing isolated heart valve replacement surgery are unclear. We investigated the effect of aspirin continuation on the risk of bleeding and transfusion in these patients. METHODS In this single center, retrospective study, among 474 adult patients who underwent isolated heart valve surgery between April 2013 and June 2018, 269 continued aspirin within 5 days before surgery (aspirin group) and 205 patients did not take or stopped aspirin no later than 5 days before surgery (non-aspirin group). The chi-square test, the Mann-Whitney U-test, and the Student's T-test were used to compare data between the groups. Univariate and Multivariate logistic regressions were used to assess crude and adjusted relationships between outcome and exposure. RESULTS The primary outcome, red blood cell (RBC) transfusion, occurred in 59 patients (22%) of the aspirin group and in 24 patients (12%) of the non-aspirin group (p = 0.004). After adjustment for confounding factors, continuation of aspirin was no longer associated with RBC transfusion (aOR1.8;95%CI,0.98-3.2;p = 0.06). The amount of allogenic blood products, the incidence of surgical re-exploration for bleeding, the volume of re-transfused cell-saved blood, and the cumulative chest tube drainage during the first 24 postoperative hours were similar between groups. CONCLUSION Preoperative continuation of aspirin in patients undergoing isolated heart valve surgery is neither associated with a higher incidence of RBC transfusion, nor with larger perioperative blood loss, or more frequent surgical revision for bleeding. TRIAL REGISTRATION Clinicaltrials.gov (NCT05151796).
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Affiliation(s)
- Alan M Houben
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
| | - Margaux Crepy
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
| | - Marc Senard
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Vincent Tchana-Sato
- Department of Cardiovascular Surgery, Liege University Hospital, Liege, Belgium
| | - Gregory Hans
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
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2
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Besnier E, Schmidely P, Dubois G, Lemonne P, Todesco L, Aludaat C, Caus T, Selim J, Lorne E, Abou-Arab O. POBS-Card, a new score of severe bleeding after cardiac surgery: Construction and external validation. JTCVS OPEN 2024; 19:183-199. [PMID: 39015466 PMCID: PMC11247224 DOI: 10.1016/j.xjon.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 04/09/2024] [Accepted: 04/13/2024] [Indexed: 07/18/2024]
Abstract
Objective Bleeding after cardiac surgery leads to poor outcomes. The objective of the study was to build the PeriOperative Bleeding Score in Cardiac surgery (POBS-Card) to predict bleeding after cardiac surgery. Methods We conducted a retrospective cohort study in 2 academic hospitals (2016-2019). Inclusion criteria were adult patients after cardiac surgery under cardiopulmonary bypass. Exclusion criteria were heart transplantation, assistance, aortic dissection, and preoperative hemostasis diseases. Bleeding was defined by the universal definition for perioperative bleeding score ≥2. POBS-Card score was built using multivariate regression (derivation cohort, one center). The performance diagnosis was assessed using the area under the curve in a validation cohort (2 centers) and compared with other scores. Results In total, 1704 patients were included in the derivation cohort, 344 (20%) with bleeding. Preoperative factors were body mass index <25 kg/m2 (odds ratio [OR], 1.48 [1.14-1.93]), type of surgery (redo: OR, 1.76 [1.07-2.82]; combined: OR, 1.81 [1.19-2.74]; ascendant aorta: OR, 1.56 [1.02-2.38]), ongoing antiplatelet therapy (single: OR, 1.50 [1.09-2.05]; double: OR, 2.00 [1.15-3.37]), activated thromboplastin time ratio >1.2 (OR, 1.44 [1.03-1.99]), prothrombin ratio <60% (OR, 1.91 [1.21-2.97]), platelet count <150 g/L (OR, 1.74 [1.17-2.57]), and fibrinogen <3 g/L (OR, 1.33 [1.02-1.73]). In the validation cohort of 597 patients, the area under the curve was 0.645 [0.605-0.683] and was superior to other scores (WILL-BLEED, Papworth, TRUST, TRACK). A threshold >14 predicted bleeding with a sensitivity of 50% and a specificity of 73%. Conclusions POBS-Card score was superior to other scores in predicting severe bleeding after cardiac surgery. Performances remained modest, questioning the place of these scores in the perioperative strategy of bleeding-sparing.
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Affiliation(s)
- Emmanuel Besnier
- Department of Anesthesiology and Critical Care, Univ Rouen Normandie, Inserm U1096, CHU Rouen, Rouen, France
| | - Pierre Schmidely
- Department of Anesthesiology and Critical Care, CHU Rouen, Rouen, France
| | - Guillaume Dubois
- Anesthesia and Critical Care Department, Amiens Hospital University, Amiens, France
| | - Prisca Lemonne
- Department of Anesthesiology and Critical Care, CHU Rouen, Rouen, France
| | - Lucie Todesco
- Department of Anesthesiology and Critical Care, CHU Rouen, Rouen, France
| | - Chadi Aludaat
- Department of Cardiac Surgery, Rouen University Hospital, Rouen, France
| | - Thierry Caus
- Department of Cardiac Surgery, Amiens University Hospital, Amiens, France
| | - Jean Selim
- Department of Anesthesiology and Critical Care, Univ Rouen Normandie, Inserm U1096, CHU Rouen, Rouen, France
| | - Emmanuel Lorne
- Anesthesia and Critical Care Medicine, Clinique du Millénaire, Cedex 2, Montpellier, France
| | - Osama Abou-Arab
- Anesthesia and Critical Care Department, Amiens Hospital University, Amiens, France
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3
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Ntalouka MP, Brotis A, Karagianni MD, Arvaniti C, Mermiri M, Solou M, Stamoulis K, Bareka M, Fountas KN, Arnaoutoglou EM. Perioperative management of antithrombotics in elective intracranial procedures: systematic review, critical appraisal. Acta Neurochir (Wien) 2024; 166:97. [PMID: 38383680 DOI: 10.1007/s00701-024-05990-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/29/2023] [Indexed: 02/23/2024]
Abstract
PURPOSE Perioperative management of patients medicated with antithrombotics requiring elective intracranial procedures is challenging. We ought to (1) identify the clinical practice guidelines (CPGs) and recommendations (CPRs) on perioperative management of antithrombotic agents in elective intracranial surgery and (2) assess their methodological quality and reporting clarity. METHODS The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered (PROSPERO, CRD42023415710). An electronic search was conducted using PubMed, Scopus, and Google Scholar. The search terms used were "adults," "antiplatelets," "anticoagulants," "guidelines," "recommendations," "english language," "cranial surgery," "brain surgery," "risk of bleeding," "risk of coagulation," and "perioperative management" in all possible combinations. The search period extended from 1964 to April 2023 and was limited to literature published in the English language. The eligible studies were evaluated by three blinded raters, by employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. RESULTS A total of 14 sets of guidelines were evaluated. Two guidelines from the European Society of Anaesthesiology and one from the American College of Chest Physicians found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. The interrater agreement was good with a mean Cohens Kappa of 0.70 (range, 46.5-94.4%) in the current analysis. CONCLUSION The perioperative management of antithrombotics in intracranial procedures may be challenging, complex, and demanding. Due to the lack of high quality data, uncertainty remains regarding the optimal practices to balance the risk of thromboembolism against that of bleeding.
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Affiliation(s)
- Maria P Ntalouka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece.
| | - Alexandros Brotis
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria D Karagianni
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Christina Arvaniti
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria Mermiri
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria Solou
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Konstantinos Stamoulis
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Metaxia Bareka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Konstantinos N Fountas
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Eleni M Arnaoutoglou
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
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Rosero EB, Rajan N, Joshi GP. Pro-Con Debate: Are Patients With Coronary Stents Suitable for Free-Standing Ambulatory Surgery Centers? Anesth Analg 2023; 136:218-226. [PMID: 36638505 DOI: 10.1213/ane.0000000000006237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
With increasing implantation of coronary artery stents over the past 2 decades, it is inevitable that anesthesiologists practicing in the outpatient setting will need to determine whether these patients are suitable for procedures at a free-standing ambulatory surgery center (ASC). Appropriate selection of patients with coronary artery stents for a procedure in an ASC requires consideration of factors that affect the balance between the risk of stent thrombosis due to interruption of antiplatelet therapy and the thrombogenic effects of surgery, and the risk of perioperative bleeding complications that may occur if antiplatelet therapy is continued. Thus, periprocedure care of these patients presents unique challenges, particularly for extensive surgical procedures that are increasingly scheduled for free-standing ASCs, where consultation and ancillary services, as well as access to percutaneous cardiac interventions, may not be readily available. Therefore, the suitability of the ambulatory setting for this patient population remains highly controversial. In this Pro-Con commentary, we discuss the arguments for and against scheduling patients with coronary artery stents in free-standing ASCs.
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Affiliation(s)
- Eric B Rosero
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
| | - Niraja Rajan
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Girish P Joshi
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
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5
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Ferrandis R, Cassinello C, Sierra P, Llau JV. "Letter to the Editor" response to Vives and Devereaux. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:373-374. [PMID: 35760693 DOI: 10.1016/j.redare.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 11/04/2021] [Indexed: 06/15/2023]
Affiliation(s)
- R Ferrandis
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, València, Spain.
| | - C Cassinello
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Pilar Sierra
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Fundació Puigvert, Barcelona, Spain
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Doctor Peset, València, Spain
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Laquet P, Pradère B, Francois M, Ravel A, Lambert C, Guy L. Résultats périopératoires de la radiofréquence sur les petites tumeurs du rein : complications, impact sur la fonction rénale et résultats oncologiques. Prog Urol 2022; 32:551-557. [DOI: 10.1016/j.purol.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 03/14/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
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Kim C, Pfeiffer ML, Chang JR, Burnstine MA. Perioperative Considerations for Antithrombotic Therapy in Oculofacial Surgery: A Review of Current Evidence and Practice Guidelines. Ophthalmic Plast Reconstr Surg 2022; 38:226-233. [PMID: 35019878 PMCID: PMC9093724 DOI: 10.1097/iop.0000000000002058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Recent survey studies have demonstrated wide variability in practice patterns regarding the management of antithrombotic medications in oculofacial plastic surgery. Current evidence and consensus guidelines are reviewed to guide perioperative management of antithrombotic medications. METHODS Comprehensive literature review of PubMed database on perioperative use of antithrombotic medication. RESULTS/CONCLUSIONS Perioperative antithrombotic management is largely guided by retrospective studies, consensus recommendations, and trials in other surgical fields due to the limited number of studies in oculoplastic surgery. This review summarizes evidence-based recommendations from related medical specialties and provides context for surgeons to tailor antithrombotic medication management based on patient's individual risk. The decision to continue or cease antithrombotic medications prior to surgery requires a careful understanding of risk: risk of intraoperative or postoperative bleeding versus risk of a perioperative thromboembolic event. Cessation and resumption of antithrombotic medications after surgery should always be individualized based on the patient's thrombotic risk, surgical and postoperative risk of bleeding, and the particular drugs involved, in conjunction with the prescribing doctors. In general, we recommend that high thromboembolic risk patients undergoing high bleeding risk procedures (orbital or lacrimal surgery) may stop antiplatelet agents, direct oral anticoagulants, and warfarin including bridging warfarin with low-molecular weight heparin. Low-risk patients, regardless of type of procedure performed, may stop all agents. Decision on perioperative management of antithrombotic medications should be made in conjunction with patient's internist, cardiologist, hematologist, or other involved physicians which may limit the role of guidelines depending on patient risk and should be used on a case-by-case basis. Further studies are needed to provide oculofacial-specific evidence-based guidelines.
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Affiliation(s)
- Christian Kim
- Eyesthetica, Los Angeles, California
- Department of Ophthalmology, Loyola University Stritch School of Medicine, Chicago, Illinois
| | - Margaret L Pfeiffer
- Eyesthetica, Los Angeles, California
- USC Roski Eye Institute, University of Southern California Keck School of Medicine, Los Angeles, California, U.S.A
| | - Jessica R Chang
- USC Roski Eye Institute, University of Southern California Keck School of Medicine, Los Angeles, California, U.S.A
| | - Michael A Burnstine
- Eyesthetica, Los Angeles, California
- USC Roski Eye Institute, University of Southern California Keck School of Medicine, Los Angeles, California, U.S.A
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8
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Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
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9
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Saka E, Canbaz M, Abdullah T, Dinc T, Polat O, Sabanci PA, Akinci IO, Tugrul KM, Ali A. Perioperative myocardial injury after elective neurosurgery: incidence, risk factors, and effects on mortality. Neurosurg Rev 2022; 45:2151-2159. [PMID: 35018524 DOI: 10.1007/s10143-021-01722-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 11/20/2021] [Accepted: 12/20/2021] [Indexed: 10/19/2022]
Abstract
Perioperative myocardial injury is an important reason of mortality and morbidity after neurosurgery. It usually is missed due to its asymptomatic character. In the present study, we investigated myocardial injury after noncardiac surgery (MINS) incidence, the risk factor for MINS, and association of MINS with 30-day mortality in neurosurgery patients. Patients with cardiac risk who underwent elective neurosurgery were enrolled to present prospective cohort study. The patients' demographics, comorbidities, medications used, medical history, and type of operation were recorded. The high-sensitivity cardiac troponin (hs-cTn) levels of the patients were measured 12, 24, and 48 h after surgery. The patients were considered MINS-positive if at least one of their postoperative hs-cTn measurement values was ≥ 14 ng/l. All the patients were followed up for 30 days after surgery for evaluation of their outcomes, including total mortality, mortality due to cardiovascular cause, and major cardiac events. A total of 312 patients completed the study and 64 (20.5%) of them was MINS-positive. Long antiplatelet or anticoagulant drug cessation time (OR: 4.9, 95% CI: 2.1-9.4) was found the most prominent risk factor for MINS occurrence. The total mortality rate was 2.4% and 6.2% in patients MINS-negative and MINS-positive, respectively (p = 0.112). The mortality rate due to cardiovascular reasons (0.8% for without MINS, 4.7 for with MINS, and p = 0.026) and incidence of the major cardiac events (4% for without MINS, 10.9 for with MINS, and p = 0.026) were significantly higher in patients with MINS. MINS is a common problem after neurosurgery, and high postoperative hs-cTn level is associated with mortality and morbidity.
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Affiliation(s)
- Esra Saka
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Mert Canbaz
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Taner Abdullah
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Tugce Dinc
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Ozlem Polat
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Pulat Akin Sabanci
- Department of Neurosurgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ibrahim Ozkan Akinci
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Kamil Mehmet Tugrul
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Achmet Ali
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey. .,İ.Ü. İstanbul Tıp Fakültesi Anesteziyoloji A.D., Turgut Özal cad, İstanbul, Türkiye.
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10
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Stonko DP, Haut ER. Review of the French Working Group on Perioperative Hemostasis, French Study Group on Thrombosis and Hemostasis, and French Society for Anaesthesia and Intensive Care Guidelines on Management of Antiplatelet Therapy for Nonelective Invasive Procedures or Bleeding Complications. JAMA Surg 2021; 155:886-887. [PMID: 32697287 DOI: 10.1001/jamasurg.2020.2162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- David P Stonko
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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11
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Bhatia K, Narasimhan B, Aggarwal G, Hajra A, Itagi S, Kumar S, Chakraborty S, Patel N, Jain V, Bandyopadhyay D, Amgai B, Aronow WS. Perioperative pharmacotherapy to prevent cardiac complications in patients undergoing noncardiac surgery. Expert Opin Pharmacother 2020; 22:755-767. [PMID: 33350868 DOI: 10.1080/14656566.2020.1856368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Despite advances in surgical and anesthetic techniques, perioperative cardiovascular complications are a major cause of 30-day perioperative mortality. Major cardiovascular complications after noncardiac surgery include myocardial ischemia, congestive heart failure, arrhythmias, and cardiac arrest. Along with surgical risk assessment, perioperative medical optimization can reduce the rates and clinical impact of these complications.Areas Covered: In this review, the authors discuss the pharmacological basis, existing evidence, and professional society recommendations for drug management in preventing cardiovascular complications in patients undergoing noncardiac surgery.Expert opinion: Perioperative management of cardiovascular disease is an increasingly important and growing area of clinical practice. Societal guidelines regarding the use of most routine cardiovascular medications are based on a number of large clinical studies and provide a basic foundation to guide management. However, the heterogeneous nature of patients, as well as surgeries, makes it practically impossible to devise a 'one size fits all' recommendation in this setting. Thus, the importance of a more individualized approach to perioperative risk stratification and management is being increasingly recognized. The underlying comorbidities and cardiac profile as well as the risk of cardiac complications associated with the planned surgery must be factored in to understand the nuance of the management strategies.
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Affiliation(s)
- Kirtipal Bhatia
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | - Bharat Narasimhan
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | | | - Adrija Hajra
- Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Soumya Itagi
- PSG Institute of Medical Sciences and Research, Coimbatore, India
| | - Shathish Kumar
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | | | | | - Dhrubajyoti Bandyopadhyay
- Icahn School of Medicine at Mount Sinai Morningside and Mount Sinai West Hospital Center, New York, NY, USA
| | | | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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12
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Dangers L, Giovannelli J, Mangiapan G, Alves M, Bigé N, Messika J, Morawiec E, Neuville M, Cracco C, Béduneau G, Terzi N, Huet I, Dhalluin X, Bautin N, Quiot JJ, Appere-de Vecchi C, Similowski T, Chenivesse C. Antiplatelet Drugs and Risk of Bleeding After Bedside Pleural Procedures: A National Multicenter Cohort Study. Chest 2020; 159:1621-1629. [PMID: 33290789 DOI: 10.1016/j.chest.2020.10.092] [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: 02/22/2020] [Revised: 09/10/2020] [Accepted: 10/29/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The decision-making on antiplatelet drug withdrawal or continuation before performing a pleural procedure is based on the balance between the risk of bleeding associated with the antiplatelet therapy and the risk of arterial thrombosis due to its interruption. Knowledge on antiplatelet therapy-associated risk of bleeding after pleural procedures is lacking. RESEARCH QUESTION Is the risk of bleeding associated with antiplatelet drugs increased in patients undergoing pleural procedures? STUDY DESIGN AND METHODS We conducted a French multicenter cohort study in 19 centers. The main outcome was the occurrence of bleeding, defined as hematoma, hemoptysis, or hemothorax, during the 24 h following a pleural procedure. Serious bleeding events were defined as bleeding requiring blood transfusion, respiratory support, endotracheal intubation, embolization, or surgery, or as death. RESULTS A total of 1,124 patients was included (men, 66%; median age, 62.6 ± 27.7 years), of whom 182 were receiving antiplatelet therapy and 942 were not. Fifteen patients experienced a bleeding event, including eight serious bleeding events. The 24-h incidence of bleeding was 3.23% (95% CI, 1.08%-5.91%) in the antiplatelet group and 0.96% (95% CI, 0.43%-1.60%) in the control group. The occurrence of bleeding events was significantly associated with antiplatelet therapy in univariate analysis (OR, 3.44; 95% CI, 1.14-9.66; P = .021) and multivariate analysis (OR, 4.13; 95% CI, 1.01-17.03; P = .044) after adjusting for demographic data and the main risk factors for bleeding. Likewise, antiplatelet therapy was significantly associated with serious bleeding in univariate analysis (OR, 8.61; 95% CI, 2.09-42.3; P = .003) and multivariate analysis (OR, 7.27; 95% CI, 1.18-56.1; P = .032) after adjusting for the number of risk factors for bleeding. INTERPRETATION Antiplatelet therapy was associated with an increased risk of post-pleural procedure bleeding and serious bleeding. Future guidelines should take into account these results for patient safety.
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Affiliation(s)
- Laurence Dangers
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Jonathan Giovannelli
- CHU Lille, Clinique de Pneumologie, Lille, France; Univ Lille, INSERM, LIRIC UMR U995, Lille, France
| | - Gilles Mangiapan
- Centre Hospitalier Intercommunal de Créteil, Service de Pneumologie et Pathologies Professionnelles, Créteil, France
| | - Mikael Alves
- APHP, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France; Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, Service de Réanimation, Poissy, France
| | - Naïke Bigé
- Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, Service de Réanimation, Poissy, France
| | - Jonathan Messika
- APHP, Hôpital Louis Mourier, Service de Réanimation Médico-Chirurgicale, Colombes, France; Sorbonne Paris Cité, Univ Paris Diderot, INSERM, IAME, UMR 1137, Paris, France
| | - Elise Morawiec
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Mathilde Neuville
- APHP, Hôpital Bichat-Claude Bernard, Service de Pneumologie, Paris, France
| | - Christophe Cracco
- Centre Hospitalier d'Angoulême Saint-Michel, Service de Réanimation Médicale, Saint-Michel, France
| | - Gaëtan Béduneau
- Centre Hospitalier Universitaire de Rouen, Service de Réanimation Médicale, Rouen, France
| | - Nicolas Terzi
- Centre Hospitalier Universitaire de Caen, Service de Réanimation Médicale, Caen, France
| | - Isabelle Huet
- Centre Hospitalier Universitaire de Toulouse, Service de Pneumologie, Toulouse, France
| | | | - Nathalie Bautin
- CHU Lille, Clinique de Pneumologie, Lille, France; Centre Hospitalier de Roubaix, Service de Pneumologie et Allergologie, Roubaix, France
| | - Jean-Jacques Quiot
- Centre Hospitalier Régional Universitaire de Brest, Département de Médecine Interne et de Pneumologie, Brest, France
| | | | - Thomas Similowski
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Cécile Chenivesse
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; CHU Lille, Clinique de Pneumologie, Lille, France; Univ Lille, INSERM, CNRS, Institut Pasteur de Lille, CIIL, U1019, UMR 8204, Lille, France.
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Gerstein NS, Albrechtsen CL, Mercado N, Cigarroa JE, Schulman PM. A Comprehensive Update on Aspirin Management During Noncardiac Surgery. Anesth Analg 2020; 131:1111-1123. [PMID: 32925332 DOI: 10.1213/ane.0000000000005064] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aspirin is considered critical lifelong therapy for patients with established cardiovascular (CV) disease (including coronary artery, cerebrovascular, and peripheral arterial diseases) and is consequently one of the most widely used medications worldwide. However, the indications for aspirin use continue to evolve and recent trials question its efficacy for primary prevention. Although one third of patients undergoing noncardiac surgery and at risk for a major adverse CV event receive aspirin perioperatively, uncertainty still exists about how aspirin should be optimally managed in this context, and significant practice variability remains. Recent trials suggest that the risks of continuing aspirin during the perioperative period outweigh the benefits in many cases, but data on patients with high CV risk remain limited. We performed a comprehensive PubMed and Medline literature search using the following keywords: aspirin, aspirin withdrawal, perioperative, coronary artery disease, cerebrovascular disease, peripheral artery disease, and CV disease; we manually reviewed all relevant citations for inclusion. Patients taking aspirin for the primary prevention of CV disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding. Patients with established CV disease but without a coronary stent should likely continue aspirin during the perioperative period unless undergoing closed-space surgery. Patients with a history of coronary stenting also likely need aspirin continuation throughout the perioperative period for nonclosed space procedures. Perioperative clinicians need to balance the risks of ceasing aspirin before surgery against its continuation during the perioperative interval using a patient-specific strategy. The guidance on decision-making with regard to perioperative aspirin cessation or continuation using currently available clinical data from studies in high-risk patients along with nonclinical aspirin studies is conflicting and does not enable a simplified or unified answer. However, pertinent guidelines on CV disease management provide a basic framework for aspirin management, and large trial findings provide some insight into the safety of perioperative aspirin cessation in some contexts, although uncertainty on perioperative aspirin still exists. This review provides an evidence-based update on perioperative aspirin management in patients undergoing noncardiac surgery with a focus on recommendations for perioperative clinicians on continuing versus holding aspirin during this context.
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Affiliation(s)
- Neal S Gerstein
- From the Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Nestor Mercado
- Division of Cardiology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Peter M Schulman
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
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P2Y 12 Inhibition beyond Thrombosis: Effects on Inflammation. Int J Mol Sci 2020; 21:ijms21041391. [PMID: 32092903 PMCID: PMC7073040 DOI: 10.3390/ijms21041391] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 02/14/2020] [Accepted: 02/15/2020] [Indexed: 12/18/2022] Open
Abstract
The P2Y12 receptor is a key player in platelet activation and a major target for antithrombotic drugs. The beneficial effects of P2Y12 receptor antagonists might, however, not be restricted to the primary and secondary prevention of arterial thrombosis. Indeed, it has been established that platelet activation also has an essential role in inflammation. Additionally, nonplatelet P2Y12 receptors present in immune cells and vascular smooth muscle cells might be effective players in the inflammatory response. This review will investigate the biological and clinical impact of P2Y12 receptor inhibition beyond its platelet-driven antithrombotic effects, focusing on its anti-inflammatory role. We will discuss the potential molecular and cellular mechanisms of P2Y12-mediated inflammation, including cytokine release, platelet–leukocyte interactions and neutrophil extracellular trap formation. Then we will summarize the current evidence on the beneficial effects of P2Y12 antagonists during various clinical inflammatory diseases, especially during sepsis, acute lung injury, asthma, atherosclerosis, and cancer.
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15
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Godier A, Bloc S. How to deal with peripheral regional anaesthesia while antithrombotics on board? Anaesth Crit Care Pain Med 2019; 38:457-459. [PMID: 31585764 DOI: 10.1016/j.accpm.2019.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Anne Godier
- Service d'anesthésie-réanimation, Hôpital Européen Georges-Pompidou, AP-HP, Paris, France; Inserm UMRS 1140, Faculté de Pharmacie, Université Paris Descartes, Paris, France.
| | - Sébastien Bloc
- CMC Ambroise-Paré, Département d'anesthésie, Neuilly-sur-Seine, France
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Joubert F, Gillois P, Bouaziz H, Marret E, Iohom G, Albaladejo P. Bleeding complications following peripheral regional anaesthesia in patients treated with anticoagulants or antiplatelet agents: A systematic review. Anaesth Crit Care Pain Med 2019; 38:507-516. [DOI: 10.1016/j.accpm.2018.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 12/16/2018] [Accepted: 12/16/2018] [Indexed: 10/27/2022]
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17
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Bridging antiplatelet therapy with cangrelor in patients with recent intracranial stenting undergoing invasive procedures: a prospective case series. Br J Anaesth 2019; 123:e2-e5. [PMID: 31010645 DOI: 10.1016/j.bja.2019.03.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 03/15/2019] [Accepted: 03/15/2019] [Indexed: 12/21/2022] Open
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18
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Samama CM, Godier A. User-friendly recommendations on antiplatelet agents: At last, a readable document. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2019; 66:1-2. [PMID: 30528241 DOI: 10.1016/j.redar.2018.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 11/19/2018] [Indexed: 06/09/2023]
Affiliation(s)
- C M Samama
- AP-HP.5 University Hospitals, Paris, Francia.
| | - A Godier
- AP-HP.5 University Hospitals, Paris, Francia
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