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Kim CH, Chang JS, Lim Y, Lim D, Kim JW. Safety of urgent surgery for the patients with proximal femur fracture treated with platelet aggregation inhibitors: a propensity-score matching analysis. Eur J Trauma Emerg Surg 2024; 50:347-358. [PMID: 37768385 DOI: 10.1007/s00068-023-02368-9] [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: 05/07/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION To compare the various perioperative outcomes in an urgent surgery setting among patients with proximal femur fracture (PFF) who received platelet aggregation inhibitors (PAIs) and those who did not. METHODS We retrospectively reviewed the data of 1,838 patients who underwent surgery for PFF between January 2011 and January 2021. We conducted 1:1 propensity-score matching and compared the perioperative outcomes, including operation time, postoperative complications, hospital stay, mortality, and variables related to bleeding risk (e.g., number of transfusion profiles, hemoglobin levels, and laboratory data, including coagulation battery). RESULTS Of the 492 patients who were treated with PAIs, 484 were 1:1 matched to the untreated control group. The PAI group showed shorter operation time than the matched control group (72.3 min for PAI vs. 77.7 min for control; P = 0.041), and the control group showed more pulmonary thromboembolism (0.2% for PAI vs 1.7% for control; P = 0.046) than the PAI group. The other complications and length of hospital stay, mortality rate, transfusion profile, and the laboratory test (except preoperative international normalized ratio, INR) showed no significant difference between the groups. Subgroup analyses of the patients treated with only aspirin (aspirin: 306, matched control: 306), only clopidogrel (clopidogrel: 100, matched control: 100), and others who were treated with dual anticoagulation (dual anticoagulation: 78, matched control: 78) showed no significant differences in perioperative outcomes among the groups. CONCLUSION The patients who were treated with PAI could undergo PFF surgery safely without delay, which led to no significant difference in operation time, postoperative complication risk, perioperative blood transfusion, and variables related to bleeding risk. Therefore, we believe that it is unnecessary to delay surgery for patients with PFF who receive PAI.
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Affiliation(s)
- Chul-Ho Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, Republic of Korea
| | - Jae Suk Chang
- Department of Orthopedic Surgery, National Police Hospital, Seoul, Republic of Korea
| | - Yaeji Lim
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Dongkyung Lim
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, Republic of Korea.
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Ghasemi MA, Ghadimi E, Shamabadi A, Mortazavi SMJ. The Perioperative Management of Antiplatelet and Anticoagulant Drugs in Hip Fractures: Do the Surgery as Early as Possible. THE ARCHIVES OF BONE AND JOINT SURGERY 2022; 10:490-500. [PMID: 35928910 PMCID: PMC9295588 DOI: 10.22038/abjs.2021.56396.2800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 09/29/2021] [Indexed: 01/24/2023]
Abstract
Hip fractures are among the most common fractures operated by orthopedic surgeons. Many elderly patients, who account for a significant percentage of hip fractures, suffer from medical conditions requiring antiplatelet and anticoagulant administration. Meanwhile, considerable evidence recommends early surgery within 48b hours of admission. We aim to review the existing evidence regarding the perioperative management of antiplatelet and anticoagulant drugs in hip fractures. It was concluded that surgery for hip fractures in patients with antiplatelet drug consumption should not be delayed unless a clear contraindication exists. Active reversal strategies are indicated for patients with hip fractures and warfarin therapy. However, evidence for the safety of these agents in pregnancy, breastfeeding state, and adolescence has not yet been established. Little data exists about perioperative management of direct-acting oral anticoagulants in hip fractures. Early surgery after 12-24 hours of drug cessation has been suggested in studies; however, it should be employed cautiously. Despite extensive research, the importance of the issue necessitates additional higher-quality studies.
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Affiliation(s)
- Mohammad Ali Ghasemi
- Joint Reconstruction Research Center, Tehran University of Medical Science, Tehran, Iran
| | - Ehsan Ghadimi
- Joint Reconstruction Research Center, Tehran University of Medical Science, Tehran, Iran
| | - Ahmad Shamabadi
- Joint Reconstruction Research Center, Tehran University of Medical Science, Tehran, Iran, School of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - SM Javad Mortazavi
- Joint Reconstruction Research Center, Tehran University of Medical Science, Tehran, Iran
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Zheng Y, Zhou Y, Yang M, Wu X, Chong H, Zheng S, Zhang W, Wang G. Evaluation of Clopidogrel Safety in Geriatric Patients with Hip Fracture: A Retrospective Study. Orthop Surg 2021; 13:1912-1921. [PMID: 34664416 PMCID: PMC8523771 DOI: 10.1111/os.13143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 06/16/2021] [Accepted: 08/02/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate the risk of bleeding in elderly patients undergoing early hip fracture surgery with/without clopidogrel administration. METHODS This was a retrospective study, and patients over 65 years with fresh hip fracture were enrolled. For the patients taking clopidogrel, early surgical treatment was performed without 5-7 days waiting time. The patients were divided into groups according to their fracture type and the surgical method. Within each fracture/surgery group, the patients were further divided into subgroups according to whether they had clopidogrel administration. The patients' age, gender, American Society of Anesthesiologists (ASA) score, hemoglobin level at admission, and the time from admission to surgery were compared in the different groups. The bleeding outcomes, such as intraoperative blood loss and blood transfusion status, as well as secondary outcomes, such as operation duration and length of hospital stay, were also compared in these groups. RESULTS There were no statistically significant differences in patients' baseline characteristics and outcomes, including intraoperative blood loss, blood transfusion rate, operation duration and length of hospital stay, between the clopidogrel-administrated patients and the control patients. However, the percentage of patients taking general anesthesia was significantly higher in clopidogrel group than that in control group (P = 0.01). Similar intraoperative blood loss was found in the subgroups of hemi-hip replacement, internal fixation for intertrochanteric fracture of the femur (fracture type A1-2, short pin), and internal fixation of femoral neck fracture with cannulated nails. For the internal fixation of femoral neck fracture with cannulated nails, the blood loss is significantly less in both subgroups than that with other two surgical methods. Moreover, the total hip arthroplasty, with the highest bleeding risk among all the surgical methods involved, was rarely chosen to treat geriatric hip fracture in this study. CONCLUSION This study indicated that compared with patients without clopidogrel administration, elderly patients with hip fractures who receive clopidogrel as long-term anti-platelet therapy are relatively safe for surgery in less than 5-7 days after discontinuation of clopidogrel.
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Affiliation(s)
- Yuanfang Zheng
- Anesthesiology Department, Beijing Jishuitan Hospital, Beijing, China
| | - Yan Zhou
- Anesthesiology Department, Beijing Jishuitan Hospital, Beijing, China
| | - Minghui Yang
- Orthopedic Trauma Department, Beijing Jishuitan Hospital, Beijing, China
| | - Xinbao Wu
- Orthopedic Trauma Department, Beijing Jishuitan Hospital, Beijing, China
| | - Hao Chong
- Anesthesiology Department, Beijing Jishuitan Hospital, Beijing, China
| | - Shaoqiang Zheng
- Anesthesiology Department, Beijing Jishuitan Hospital, Beijing, China
| | - Wenchao Zhang
- Anesthesiology Department, Beijing Jishuitan Hospital, Beijing, China
| | - Geng Wang
- Anesthesiology Department, Beijing Jishuitan Hospital, Beijing, China
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Rostagno C, Falchetti G, Rostagno AC, Mattesini A. TAVR in patients with hip fracture and severe aortic stenosis: how and when? Intern Emerg Med 2021; 16:1419-1422. [PMID: 34014487 DOI: 10.1007/s11739-021-02752-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
Comorbidities are common in elderly patients with hip fracture and are associated with an increased mortality after surgery. Internal medicine/geriatric leaded multidisciplinary hip fracture teams may play a pivotal role in the clinical management of complex patients. Treatment strategy is particular relevant in patients with severe aortic stenosis that represent more than 5% of patients with hip fracture. These patients have a high in-hospital mortality and poor 1-year survival (less than 50%). Transcatheter aortic valve replacement (TAVR) may be an option in selected patients; however, the choice to treat and, in the case, the timing of valve replacement in relation to hip surgery is highly dependent on clinical conditions before trauma. In this paper, three different scenario of TAVR timing after hip fracture are reported.
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Affiliation(s)
- Carlo Rostagno
- Dipartimento Medicina Sperimentale e Clinica, Università di Firenze, Viale Morgagni 85, 50134, Florence, Italy.
| | - Giorgia Falchetti
- Dipartimento Medicina Sperimentale e Clinica, Università di Firenze, Viale Morgagni 85, 50134, Florence, Italy
| | - Andrea Carlo Rostagno
- Dipartimento Medicina Sperimentale e Clinica, Università di Firenze, Viale Morgagni 85, 50134, Florence, Italy
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Reinke CE, Lim RB. Minimally Invasive Acute Care Surgery. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Reinke CE, Lim RB. Minimally invasive acute care surgery. Curr Probl Surg 2021; 59:101031. [DOI: 10.1016/j.cpsurg.2021.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/16/2021] [Indexed: 12/07/2022]
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Kain MS, Saper D, Lybrand K, Bramlett KJ, Tornetta III P, Althausen P, Garfi JS, Willier III DP, Niu R, Marcantonio AJ. Postoperative Complications of Hip Fractures Patients on Chronic Coumadin: A Comparison Based on Operative International Normalized Ratio. Geriatrics (Basel) 2020; 5:geriatrics5030043. [PMID: 32679667 PMCID: PMC7555195 DOI: 10.3390/geriatrics5030043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 11/29/2022] Open
Abstract
In current clinical practice, orthopedic surgeons often delay the surgery intervention on geriatric hip fracture patients to optimize the international normalized ratio (INR), in order to decrease the risk of postoperative hematological complications. However, some evidence suggests that full reversal protocols may not be necessary, especially for patients with prior thromboembolic history. Our study aims to compare the surgical outcomes of patients with normal versus elevated INR values. We conducted a retrospective chart review on 217 patients who underwent surgeries on hip fractures at two academic trauma centers. We found that in our group (n = 124) of patients with an INR value of 1.5–3.0, there was only one reoperation for a hematoma, but there was a trend for more blood transfusions. There was no statistically significant difference in the odds of reoperation or overall complications. Nevertheless, there were significantly more events of postoperative anemia in this high INR patient group.
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Affiliation(s)
- Michael S. Kain
- Department of Orthopaedic Surgery, Boston Medical Center, 850 Harrison Avenue, Boston, MA 02118, USA; (P.T.III); (R.N.)
- Correspondence:
| | - David Saper
- Orthopaedic and Rehabilitation Centers, 5616 North Western Avenue, Chicago, IL 60659, USA;
| | - Kyle Lybrand
- Ortho Montana, 2900 12th Avenue North, Billings, MT 59101, USA;
| | - Kasey-Jean Bramlett
- Department of Orthopaedic Surgery, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, MA 01805, USA; (K.-J.B.); (J.S.G.); (D.P.W.III); (A.J.M.)
| | - Paul Tornetta III
- Department of Orthopaedic Surgery, Boston Medical Center, 850 Harrison Avenue, Boston, MA 02118, USA; (P.T.III); (R.N.)
| | | | - John S. Garfi
- Department of Orthopaedic Surgery, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, MA 01805, USA; (K.-J.B.); (J.S.G.); (D.P.W.III); (A.J.M.)
| | - Donald P. Willier III
- Department of Orthopaedic Surgery, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, MA 01805, USA; (K.-J.B.); (J.S.G.); (D.P.W.III); (A.J.M.)
| | - Ruijia Niu
- Department of Orthopaedic Surgery, Boston Medical Center, 850 Harrison Avenue, Boston, MA 02118, USA; (P.T.III); (R.N.)
| | - Andrew J. Marcantonio
- Department of Orthopaedic Surgery, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, MA 01805, USA; (K.-J.B.); (J.S.G.); (D.P.W.III); (A.J.M.)
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Evaluation of the use of anti-platelet therapy throughout the peri-operative period in patients with femoral neck fracture surgery. A retrospective cohort study. INTERNATIONAL ORTHOPAEDICS 2020; 44:1805-1813. [PMID: 32447430 DOI: 10.1007/s00264-020-04633-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/12/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Fracture neck of femur (hip fracture) is a very common problem among old age group. Such elderly patients usually have some comorbidities for which they may use anti-platelet therapy (such as clopidogrel, aspirin, or others) for long duration (chronic use). These anti-platelet medications might make the blood thin and increase bleeding tendency. So, if these elderly people present with fracture neck of femur requiring surgical intervention, they might be at increased risk of bleeding and other complications if the use of these anti-platelet agents was continued throughout the peri-operative period. OBJECTIVES This current study aims to find out whether it is safe or not to continue the use of anti-platelet drugs during the peri-operative period in patients with hip fracture surgery. If it is safe and there are no complications, then there is no harm to continue the use of these drugs peri-operatively without any surgical delay. But if it is unsafe and there is increased risk of bleeding or blood transfusion or other complications, then such medications must be stopped peri-operatively. Thus, the medical practice and care will be improved to achieve patient safety. METHODS It was a retrospective study which reviewed files and notes of patients who had hip fracture surgery. These patients were divided into 2 groups. First group was on long-term anti-platelet treatment (APTG), and the use of these medicines continued during the peri-operative phase. The second group was not on anti-platelet treatment at all (NAPTG). Then, a comparison was done between both groups in terms of the following parameters during the peri-operative (pre- and post-operative) period: (i) intra-operative blood loss, (ii) operative time in minutes (length of surgery), (iii) pre-operative haemoglobin level, (iv) the need for blood transfusion, (v) haematoma formation, (vi) re-operation for any reason, (vii) post-operative wound infection, and (viii) duration in days to achieve complete wound healing post-operatively. So these measures are good parameters to assess bleeding tendency and bleeding risk. Data was collected, and statistical analysis was done using Pearson's chi-squared test and independent sample t test as appropriate. RESULTS 325 participants were enrolled in the study. There were 163 patients in the APTG (Anti-Platelet Treatment Group) and 162 patients in the NAPTG (Non-Anti-Platelet Treatment Group). It has been found that there was no statistically significant difference between the APTG and NAPTG in terms of these peri-operative parameters: (i) intra-operative blood loss, (ii) operative time in minutes (length of surgery), (iii) pre-operative haemoglobin level, (iv) the need for blood transfusion, (v) haematoma formation, (vi) re-operation for any reason, (vii) post-operative wound infection, and (viii) duration in days to achieve complete wound healing post-operatively (P > 0.650). CONCLUSION It is safe to continue the use of anti-platelet therapy throughout the peri-operative phase in patients with hip fracture surgery. The continuation of such therapy is not associated with increased risk of bleeding or blood transfusion or other complications in patients who had surgical treatment for femoral neck fracture.
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Yang Z, Ni J, Long Z, Kuang L, Gao Y, Tao S. Is hip fracture surgery safe for patients on antiplatelet drugs and is it necessary to delay surgery? A systematic review and meta-analysis. J Orthop Surg Res 2020; 15:105. [PMID: 32164755 PMCID: PMC7068917 DOI: 10.1186/s13018-020-01624-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/04/2020] [Indexed: 12/28/2022] Open
Abstract
Background Hip fractures are common and account for a large proportion of orthopedic surgical admissions in elderly patients. However, determining the timing for surgery has been controversial for patients who develop hip fractures while on antiplatelet treatment. Methods Computerized databases for studies published from the inception date to January 2020, including the Cochrane Library, PubMed (Medline), EMBASE, Web of ScienceTM, ClinicalTrials, ClinicalKey, and Google Scholar, were searched using the keywords “Hip AND Fracture”, “Antiplatelet”, “Antithrombocyte”, “Platelet aggregation inhibitors”, “Aspirin”, “Plavix”, and “Clopidogrel”. Results In total, 2328 initial articles were identified. Twenty-four studies with 5423 participants were ultimately included in our analysis. Early surgery was associated with an increased transfusion rate in the antiplatelet group compared to the non-antiplatelet group (OR = 1.21; 95% CI, 1.01 to 1.44; p = 0.03). Early surgery for hip fracture patients on antiplatelet therapy was associated with a greater decrease in hemoglobin compared to delayed surgery (WMD = 0.75; 95% CI, 0.50 to 1.00; p < 0.001). However, early surgery appeared to decrease the length of hospitalization (WMD = − 6.05; 95% CI, − 7.06 to − 5.04; p < 0.001) and mortality (OR = 0.43; 95% CI, 0.23 to 0.79; p = 0.006). Conclusion It is unnecessary to delay surgery to restore platelet function when patients with hip fractures receive antiplatelet therapy. Furthermore, early surgery can significantly reduce mortality and hospital stay, which is conducive to patient recovery. Future randomized trials should determine whether the results are sustained over time.
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Affiliation(s)
- Zhanyu Yang
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Jiangdong Ni
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China.
| | - Ze Long
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Letian Kuang
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Yongquan Gao
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Shibin Tao
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
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Ueoka K, Sawaguchi T, Goshima K, Shigemoto K, Iwai S, Nakanishi A. The influence of pre-operative antiplatelet and anticoagulant agents on the outcomes in elderly patients undergoing early surgery for hip fracture. J Orthop Sci 2019; 24:830-835. [PMID: 30709788 DOI: 10.1016/j.jos.2018.12.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 12/24/2018] [Accepted: 12/26/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Early surgery improves the prognosis of elderly patients with hip fractures. However, many patients take antiplatelet and anticoagulant therapies for comorbidities. This study compared perioperative outcomes and 1-year mortality rates with early surgery in elderly patients with hip fractures taking or not taking these agents preoperatively. METHODS Among 418 patients undergoing surgery for hip fractures at our institution from 2014 to 2016, 266 patients over 65 years who had surgery within 48 hours of admission were enrolled. We excluded patients with high-energy injuries, multiple or pathological fractures, and patients undergoing osteosynthesis for femoral neck fractures. The study population was divided into those who underwent hemiarthroplasty for neck fractures and those who underwent osteosynthesis for trochanteric fractures. We also divided the population into patients receiving chronic anticoagulation therapy (medicated group: 19 hemiarthroplasty, 70 osteosynthesis) and patients not receiving anticoagulation therapy (non-medicated group: 47 hemiarthroplasty, 130 osteosynthesis). Comorbidities, intraoperative blood loss, estimated blood loss from admission to the first and seventh day after surgery, transfusions, length of stay, complications, and 1-year mortality rates were evaluated. RESULTS Diabetes mellitus and cerebrovascular disorders were significantly more common in the medicated group for both surgery types. In the osteosynthesis group, estimated blood loss on the first day was 710 ml in the medicated group and 572 ml in the non-medicated group (P = 0.015). In the hemiarthroplasty group, corresponding values were 668 and 480 ml, respectively (P = 0.016). Estimated blood loss on the seventh day, complications, length of stay and 1-year mortality rate were not increased significantly. CONCLUSIONS The medicated group had an increase in estimated blood loss on the first day. However, there was no significant increase in transfusions, complications and 1-year mortality rates. Early surgery for elderly patients with hip fractures is recommended, even for those taking antiplatelet and anticoagulant agents.
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Affiliation(s)
- Ken Ueoka
- Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan.
| | - Takeshi Sawaguchi
- Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
| | - Kenichi Goshima
- Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
| | - Kenji Shigemoto
- Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
| | - Shintaro Iwai
- Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
| | - Akira Nakanishi
- Department of Orthopedic Surgery and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
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Safety of Continued Clopidogrel Use in the Preoperative Course of Gastrointestinal Surgery: A Retrospective Cohort Study. Ann Surg 2017; 265:370-378. [PMID: 27049768 DOI: 10.1097/sla.0000000000001726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Our study aimed to estimate postoperative bleeding risk in older adults taking clopidogrel before gastrointestinal (GI) surgery, to aid surgeons in decisions regarding clopigogrel cessation. SUMMARY BACKGROUND DATA Balancing risks of postoperative bleeding associated with continued clopidogrel use and those associated with cessation is difficult for GI surgeons. METHODS Using 100% Texas Medicare Claims Data from 2006 to 2011, we identified patients undergoing emergent GI surgery. We propensity score matched patients on clopidogrel before surgery to patients not on clopidogrel. Using conditional logistic regression, we compared risks of bleeding events at 1-month postdischarge between groups, adjusting for bleeding risk factors. RESULTS In total, 1240 patients undergoing emergent GI surgery while treated with clopidogrel were matched to emergency GI surgery patients not treated with clopidogrel. The only significant preoperative differences between groups were higher percent of clopidogrel-treated patients with congestive heart failure, cholecystectomy, and lower percent of clopidogrel-treated patients with colectomy. Mean age was 76.91 (±7.06) and 76.70 (±7.05) years (P = 0.47), and 63.84% and 59.41% of operations were cholecystectomy, in the clopidogrel and nonclopidogrel groups (P = 0.18). In multivariable analyses adjusting for Elixhauser index, hyperlipidemia, confounding drugs, and surgery type, odds ratio for bleeding within 30 days of discharge in those exposed to clopidogrel compared with those not exposed was 1.60 (95% confidence interval, 1.08-2.38), with raw rates of bleeding 6.85% and 4.84%. CONCLUSIONS Clopidogrel use in older adults through the preoperative period of GI surgery does not significantly increase bleeding events in the month after surgery.
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Saleh J, El-Othmani MM, Saleh KJ. Deep Vein Thrombosis and Pulmonary Embolism Considerations in Orthopedic Surgery. Orthop Clin North Am 2017; 48:127-135. [PMID: 28336037 DOI: 10.1016/j.ocl.2016.12.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Patients undergoing orthopedic surgery have an increased risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). These complications are considered detrimental, as they cause major postoperative morbidity and mortality and lead to a substantial health care burden. Because of the high incidence and serious nature of these complications, it is essential for orthopedic surgeons to have a comprehensive knowledge of the risk factors, diagnosis, and treatment of acute DVT and PE. Perioperative management of orthopedic patients to prevent postoperative DVT and PE and optimize postoperative outcomes is also discussed in this review.
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Affiliation(s)
- Jasmine Saleh
- Department of Research Institute, National Institute of Health, 9000 Rockville Pike Street, Bethesda, MD 20892, USA
| | - Mouhanad M El-Othmani
- Department of Orthopaedics and Sports Medicine, Detroit Medical Center, University Health Center (UHC), 4201 Saint Antoine Street, 9B, Detroit, MI 48201-2153, USA
| | - Khaled J Saleh
- Department of Orthopaedics and Sports Medicine, Detroit Medical Center, University Health Center (UHC), 4201 Saint Antoine Street, 9B, Detroit, MI 48201-2153, USA.
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Omar HR, Socias SM, Powless RA, Sprenker C, Karlnoski R, Mangar D, Camporesi EM. Clopidogrel is not associated with increased bleeding complications after full-mouth extraction: A retrospective study. J Am Dent Assoc 2016; 146:303-9. [PMID: 25925522 DOI: 10.1016/j.adaj.2015.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 01/02/2015] [Accepted: 01/02/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND To the authors' knowledge, the effect of clopidogrel on bleeding complications during full-mouth extraction has not been studied. The authors aimed to determine the safety of continued use of clopidogrel during full-mouth extraction. METHODS The authors performed a retrospective study of consecutive patients undergoing full-mouth extraction who were taking aspirin, clopidogrel, a combination of aspirin and clopidogrel, or neither. The main study outcomes in the 4 study groups were estimated blood loss, transfusion requirements, and complications. The authors also examined the correlation between the number of teeth extracted and estimated blood loss in various groups. RESULTS Seventy-one patients underwent full-mouth extraction with removal of an average of 19 teeth. The authors excluded 3 patients owing to lack of data regarding blood loss. Of the remaining 68 patients, 25 were using aspirin, 12 were using clopidogrel, 9 were using both aspirin and clopidogrel, and 22 had discontinued the use of antiplatelets. There was no significant difference in the number of teeth extracted (P = .283) and estimated blood loss (P = .111) among the 4 groups. The authors found a significant moderate correlation between the number of teeth extracted and estimated blood loss in the group using aspirin (r = 0.537; P = .006) and in the group using clopidogrel, whether alone or in combination with aspirin (r = 0.535; P = .012), but not in the group who discontinued the use of antiplatelets. There was no need for blood transfusion in any patient. CONCLUSIONS The results of this study provide limited evidence to suggest that continuation of clopidogrel during full-mouth extraction and preprosthetic surgery may be safe and does not appear to be associated with a significant risk of bleeding. PRACTICAL IMPLICATIONS Clopidogrel therapy during full-mouth extraction is not associated with significant bleeding complications and may be continued in patients who have a high risk of experiencing a cardiac event.
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Discontinuation of Plavix ® (clopidogrel) for hip fracture surgery. A systematic review of the literature. Orthop Traumatol Surg Res 2016; 102:1097-1101. [PMID: 27863918 DOI: 10.1016/j.otsr.2016.08.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/06/2016] [Accepted: 08/24/2016] [Indexed: 02/02/2023]
Abstract
UNLABELLED The elderly population is increasing worldwide, associated with an increase in diseases related to aging, such as hip fractures. These patients are sometimes treated with clopidogrel. There are no arguments at present to clearly determine the risk/benefit ratio of early surgical management of traumatic hip fractures in patients treated with clopidogrel (perioperative blood loss, postoperative complications). The goal of this systematic review of the literature was to show that early surgical management (<48h) of patients treated with clopidogrel does not increase postoperative morbidity or mortality. Systematic review of the literature: level of evidence IV. A bibliographic search was performed in July 2015 in PubMed, Embase and Cochrane databases using the MeSh keywords "Clopidogrel or Plavix®" AND "hip fracture". Two of the authors analyzed 48 articles based on the title and abstract. Twenty-one articles were selected and read completely with an analysis of the references. Nine articles were chosen. Early surgical management (<48h) of patients receiving clopidogrel did not increase mortality at 30days, 3months or 1 year (between 25 and 30% mortality at 1 year) and did not result in an increase in perioperative bleeding. The risk/benefit ratio of early surgical management of patients with hip fractures receiving clopidogrel is good; morbidity and mortality are not increased in these patients if surgery is performed immediately or less than 48h after admission. LEVEL OF EVIDENCE IV.
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Schweer D, Carmouche JJ, Jupiter D, Ball T, Clements JR. Evaluating Blood Loss and the Effect of Antiplatelet Treatment in Foot and Ankle Amputations. J Foot Ankle Surg 2016; 55:1210-1215. [PMID: 27614827 DOI: 10.1053/j.jfas.2016.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Indexed: 02/03/2023]
Abstract
The interrelationship between diabetes mellitus and cardiovascular disease is well-documented, and, secondary to the latter, is the use of antiplatelet therapy. Although diabetes and the associated vascular manifestations are driving forces behind lower extremity amputations, few data are available on the risks of perioperative antiplatelet therapy with foot and ankle amputations. The goal of the present study was to address the surgical effect of continuing or discontinuing antiplatelet therapy before foot and/or ankle amputation. The following data were retrospectively collected: blood loss, pre- and postoperative hematocrit and hemoglobin, operative time, amputation type, age, diabetic status, antiplatelet treatment, and number of transfusions during the perioperative period. Perioperative antiplatelet therapy was defined as exposure to aspirin or clopidogrel within 3 days before surgery. To compare the outcomes between groups, the following factors were analyzed using bivariate analyses and then multivariate regression models: (1) the need for transfusions, (2) high blood loss (>20 mL), (3) volume of blood loss, and (4) operative time. The noninferiority of continued antiplatelet use was assessed in terms of operative time and blood loss, using a noninferiority margin of 10 minutes or 10 mL, respectively. Antiplatelet therapy was not a statistically significant risk factor for any of the studied outcomes on multivariate analysis. Equivalence testing revealed that continuing antiplatelet therapy is not inferior to discontinuing perioperative therapy in terms of blood loss and operative time. Multivariate analysis of the data suggested that antiplatelet therapy has no statistically significant impact on blood loss, transfusion rate, or operative time.
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Affiliation(s)
- David Schweer
- Department of Orthopaedics, Carilion Clinic, Musculoskeletal Education and Research Center, Virginia Tech-Carilion School of Medicine and Research Institute, Roanoke, VA
| | - Jonathon J Carmouche
- Department of Orthopaedics, Carilion Clinic, Musculoskeletal Education and Research Center, Virginia Tech-Carilion School of Medicine and Research Institute, Roanoke, VA
| | - Daniel Jupiter
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Timothy Ball
- Department of Cardiology, Carilion Clinic, Virginia Tech-Carilion School of Medicine and Research Institute, Roanoke, VA
| | - J Randolph Clements
- Department of Orthopaedics, Carilion Clinic, Musculoskeletal Education and Research Center, Virginia Tech-Carilion School of Medicine and Research Institute, Roanoke, VA.
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Iavecchia L, Safiya A, Salat D, Sabaté M, Bosch M, Biarnés A, Camps A, Castellà D, Lalueza P, Pons V, Teixidor J, Villar MM, Agustí A. Impact of Implementing a Protocol on the Perioperative Management in Patients Treated with Antithrombotics Admitted for Hip Fracture Surgery: an Observational Study. Basic Clin Pharmacol Toxicol 2016; 119:476-484. [PMID: 27151175 DOI: 10.1111/bcpt.12615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/29/2016] [Indexed: 12/11/2022]
Abstract
This study aimed to describe the impact of implementing a protocol on the perioperative management of patients admitted for hip fracture treated with antithrombotics. A protocol was designed based on the recommendations from the American College of Chest Physicians (ACCP). After its implementation (May 2012), information on antithrombotic management was collected from admission to 3 months after surgery in retrospective (October 2011-March 2012) and prospective (October 2012-March 2013) cohorts. Patients' thromboembolic risk was classified into high, moderate or low according to the ACCP categories. A total of 113 and 101 cases were included in the retrospective and prospective cohorts, respectively. No differences in age, gender, American Society of Anaesthesiology score or thrombotic risk categories were observed between cohorts. Most patients were treated with aspirin or triflusal (55.1% and 48.1% in each cohort, respectively), clopidogrel (24.5% and 26.6%) or acenocoumarol (16.3% and 20.2%). In moderate to high thromboembolic risk patients, a higher rate of bridging therapy with full doses of enoxaparin (18.5% and 50%, p = 0.04 before and 9.1% and 43.7%, p = 0.02 after surgery) and a lower rate of aspirin discontinuation (76% and 55.3%, p = 0.03) were observed in the prospective cohort. Both cohorts had a similar percentage of cases with bleeding (68.1% and 68.3%) and thrombotic events (11.5% and 13%). No differences in the timing between surgery and the discontinuation or resumption of antithrombotics were noted. After the protocol implementation, aspirin was less often stopped and bridging therapy with therapeutic doses of enoxaparin was used more often. However, interruption and resumption times of antithrombotics remained almost unchanged. In order to achieve these goals, more efforts should be made to implement the protocol in clinical practice.
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Affiliation(s)
- Luján Iavecchia
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Pharmacology, Therapeutics and Toxicology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Ahmad Safiya
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Pharmacology, Therapeutics and Toxicology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - David Salat
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain.,Clinical Pharmacology Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Mònica Sabaté
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Pharmacology, Therapeutics and Toxicology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain.,Clinical Pharmacology Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Montse Bosch
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Pharmacology, Therapeutics and Toxicology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain.,Clinical Pharmacology Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Alfons Biarnés
- Anaesthesia and Resuscitation Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Angels Camps
- Anaesthesia and Resuscitation Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Dolors Castellà
- Blood and Tissue Bank, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Pilar Lalueza
- Pharmacy Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Verònica Pons
- Haematology and Hemostasia Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jordi Teixidor
- Orthopaedics and Traumatology Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Maria M Villar
- Internal Medicine Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Antònia Agustí
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain. .,Department of Pharmacology, Therapeutics and Toxicology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain. .,Clinical Pharmacology Service, Vall d'Hebron University Hospital, Barcelona, Spain.
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18
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Soo CGKM, Della Torre PK, Yolland TJ, Shatwell MA. Clopidogrel and hip fractures, is it safe? A systematic review and meta-analysis. BMC Musculoskelet Disord 2016; 17:136. [PMID: 27005816 PMCID: PMC4804516 DOI: 10.1186/s12891-016-0988-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/16/2016] [Indexed: 12/22/2022] Open
Abstract
Background Femoral neck fractures in the elderly make up a large proportion of Orthopaedic surgical admissions each year. Operating on patients with clopidogrel poses a challenge because of the risk of bleeding and the difficulty deciding the optimal timing of surgery. The aim of this systematic review is to examine the published evidence to establish a set of guidelines for approaching neck of femur patients who are on clopidogrel. Methods All comparative studies with an intervention group and a control group were considered. Data on patient blood transfusion exposures, units transfused, haemoglobin concentration and drop in haemoglobin were extracted and pooled using the fixed effects model. Heterogeneity of the intervention effect was assessed with the I2 statistic. Results A total of 4219 studies were identified. After removal of duplicates and after exclusion criteria were applied, there were 14 studies to be included. All 14 were case series with controls. There was no significant heterogeneity amongst the studies. Pooled odds ratio for transfusion exposures was 1.24 (95 % confidence interval 0.91 to 1.71) however this was not statistically significant (p = 0.14). No significant mean differences were found for other primary outcome measures. Conclusions On the available evidence, we recommend that these patients can be managed by normal protocols with early surgery. Operating early on patients on clopidogrel is safe and does not appear to confer any clinically significant bleeding risk. As reported in other studies, we believe clopidogrel, if possible, should not be withheld throughout the perioperative period due to increased risk of cardiovascular events associated with stopping clopidogrel. Care should be taken intraoperatively to minimise blood loss due to the increased potential for bleeding. Trial registration This systematic review and meta-analysis has been registered on Research Registry on July 16, 2015. The Review Registry Unique Identifying Number is: reviewregistry61. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-0988-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christopher G K M Soo
- Orthopaedic surgery department, Port Macquarie Base Hospital, Wrights Rd, Port Macquarie, NSW, 2444, Australia.
| | - Paul K Della Torre
- Orthopaedic surgery department, Concord Repatriation General Hospital, Hospital Rd, Concord, NSW, 2139, Australia
| | - Tristan J Yolland
- Orthopaedic surgery department, John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW, 2305, Australia
| | - Michael A Shatwell
- Orthopaedic surgery department, Port Macquarie Base Hospital, Wrights Rd, Port Macquarie, NSW, 2444, Australia
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Petchara S, Paphon S, Vanlapa A, Boontikar P, Disya K. Combined Lumbar-Sacral Plexus Block in High Surgical Risk Geriatric Patients undergoing Early Hip Fracture Surgery. Malays Orthop J 2015; 9:28-34. [PMID: 28611906 PMCID: PMC5393131 DOI: 10.5704/moj.1511.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: To evaluate the postoperative outcome after using combined lumbar and sacral plexus block (CLSB), as a sole anesthetic method in hip fracture (HF) surgery in highrisk geriatric patients. Materials and Methods: A single-center retrospective study was conducted, between 2010 and 2012, on 70 elderly HF patients with American Society of Anesthesiologists grading III-IV who underwent early surgical intervention with our CLSB protocol. Perioperative data, outcome, and complications were recorded. Results: Forty-eight patients (69%) had ongoing anticoagulant medication. Postoperatively, all patients were hemodynamically stable and awake. None of them required general anesthesia conversion. Minor anesthetic-related complications were found in nine patients. One patient (1%) died from sepsis due to pneumonia. Patients’ satisfactions were all rated as very good or excellent. Conclusion: CLSB is an interesting anesthetic option in HF surgery, especially in high surgical risk geriatric patients. This method offers an excellent clinical efficiency and high patients’ satisfaction without serious complications.
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Affiliation(s)
- S Petchara
- Department of Anesthesiology, Ramathibodi Hospital, Bangkok, Thailand
| | - S Paphon
- Department of Orthopedics, Ramathibodi Hospital, Bangkok, Thailand
| | - A Vanlapa
- Department of Anesthesiology, Ramathibodi Hospital, Bangkok, Thailand
| | - P Boontikar
- Department of Anesthesiology, Ramathibodi Hospital, Bangkok, Thailand
| | - K Disya
- Department of Anesthesiology, Ramathibodi Hospital, Bangkok, Thailand
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Clareus A, Fredriksson I, Wallén H, Gordon M, Stark A, Sköldenberg O. Variability of platelet aggregation in patients with clopidogrel treatment and hip fracture: A retrospective case-control study on 112 patients. World J Orthop 2015; 6:439-445. [PMID: 26085986 PMCID: PMC4458495 DOI: 10.5312/wjo.v6.i5.439] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/14/2015] [Accepted: 05/11/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify the rate of non-responders to clopidogrel treatment in hip fracture patients and study how non-responders differ from controls.
METHODS: In a retrospective case-control study we included 28 cases of acute proximal femoral fracture with clopidogrel treatment 2011 to 2013. Eighty-four controls from the same time period were included. Data collected included response to clopidogrel measured with multiple electrode aggregometry (MEA), intraoperative bleeding, erythrocyte transfusion, time to surgery and the incidence of adverse events up to 3 mo after surgery.
RESULTS: Eight (29%) of the 28 cases were non-responders. The median intraoperative bleeding was 300 mL (range, 0-1500), and was lower for non-responders (50 mL) but did not reach statistical significance. Erythrocyte transfusions did not differ between responders, non-responders and controls. Forty-five (40%) of 112 patients had adverse events postoperatively but the rate did not differ between patients with and without clopidogrel treatment.
CONCLUSION: Almost one-third of patients with clopidogrel treatment and an acute proximal femoral fracture are non-responders to antiplatelet therapy and can be operated without delay.
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Doleman B, Moppett IK. Is early hip fracture surgery safe for patients on clopidogrel? Systematic review, meta-analysis and meta-regression. Injury 2015; 46:954-62. [PMID: 25818054 DOI: 10.1016/j.injury.2015.03.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 12/29/2014] [Accepted: 03/05/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Hip fracture is a common presentation in the elderly population, many of whom will be taking the antiplatelet clopidogrel, which has the potential to increase perioperative bleeding. The aim of this systematic review and meta-analysis was to answer the questions: (1) is early hip fracture surgery for patients on clopidogrel associated with worse postoperative outcomes compared to patients not on clopidogrel? (2) is early versus delayed surgery for these patients associated with worse postoperative outcomes? METHODS A systematic search was conducted of MEDLINE, EMBASE, Cinahl and AMED databases. Results from patients undergoing early surgery on clopidogrel were compared to a control group not taking clopidogrel. In addition, patients taking clopidogrel undergoing early and delayed surgery were compared. RESULTS For patients taking clopidogrel undergoing early surgery, there was no associated increase in overall mortality (OR 0.89; 95% CI: 0.58-1.38) or 30-day mortality (OR 1.10 95% CI: 0.48-2.54). However, there was an associated increase in blood transfusion (OR 1.41 95% CI: 1.00-1.99). There was an associated decreased length of stay in the early surgery versus delayed surgery group (weighted mean difference -7.09 days (95% CI: -10.14 to -4.04). DISCUSSION Early surgery appears safe for patients with hip fracture though there may be a small increase in the rate of blood transfusion. However, larger prospective trials are required to confirm these findings.
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Affiliation(s)
- B Doleman
- Anaesthesia and Critical Care Research Group, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - I K Moppett
- Anaesthesia and Critical Care Research Group, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom.
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Modern Patient Blood Management in Arthroplasty. PERIOPERATIVE MEDICAL MANAGEMENT FOR TOTAL JOINT ARTHROPLASTY 2015. [PMCID: PMC7123738 DOI: 10.1007/978-3-319-07203-6_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
One of the oldest and still commonest procedures in clinical practice, allogeneic blood transfusion (ABT), is not fully supported by available evidence. In the last few decades, increasing concerns about unfavorable outcomes associated with ABT, anticipation of future insufficient blood supply, and awareness of the cost (direct and indirect) of transfusion have led to the promotion of patient blood management (PBM) as a cost-effective strategy, beneficial for patients as well as for society (Shander et al. 2010). PBM programs utilize a series of measures with a proven ability to reduce ABT and to be cost-effective. Despite that the impact of PBM on patient clinical outcomes needs to be fully defined and future studies are needed, PBM should be adopted as a new standard of care.
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Abstract
Worldwide, cardiovascular events represent the major cause of morbidity and mortality. A key role in the pathogenesis of these events is played by platelets. Interventional procedures, with placement of coronary and vascular stents, often represent the preferred therapeutic strategy. Antiplatelet medications are considered first-line therapy in preventing cardiovascular thrombotic events. A wide array of antiplatelet agents is available, each with different pharmacological properties. When patients on antiplatelet agents present for surgery, the perioperative team must design an optimal strategy to manage antiplatelet medications. Each patient is stratified according to risk of developing a cardiovascular thrombotic event and inherent risk of surgical bleeding. After risk stratification analysis, various therapeutic pathways include continuing or discontinuing all antiplatelet agents or maintaining one antiplatelet agent and discontinuing the other. This review focuses on the pharmacological and pharmacokinetic properties of both older and novel antiplatelet drugs, and reviews current literature and guidelines addressing options for perioperative antiplatelet management.
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Affiliation(s)
- A D Oprea
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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25
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Multi-disciplinary care of the patient with acute hip fracture: How to optimise the care for the elderly, traumatised patient at and around the time of the fracture to ensure the best short-term outcome as a foundation for the best long-term outcome. Best Pract Res Clin Rheumatol 2013; 27:717-30. [DOI: 10.1016/j.berh.2014.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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