The effect of aspirin on blood loss and transfusion requirements in patients with femoral neck fractures

Safety of Early Surgery in Hip Fracture Patients Taking Clopidogrel and/or Aspirin: A Systematic Review and Meta-Analysis

BACKGROUND

The aim of this study was to investigate the safety of early surgery in hip fracture patients who took clopidogrel and/or aspirin.

METHODS

A systematic search was conducted using databases, including PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science, for studies relating to early arthroplasty or internal fixation for femoral neck fractures, intertrochanteric fractures, and subtrochanteric fractures in patients taking clopidogrel and/or aspirin. A total of 20 observational studies involving 3,077 patients were included in this meta-analysis, and analyzed in groups of early surgery versus delayed surgery, and clopidogrel and/or aspirin versus nonantiplatelet agents.

RESULTS

Patients in the clopidogrel and/or aspirin group who underwent early surgery had significantly more intraoperative blood loss than those in the non-antiplatelet group (mean difference = 17.96, 95% confidence interval [CI] [4.37, 31.55], P = .01), and patients in the clopidogrel and/or aspirin group had a lower overall incidence of complications after early surgery than those in the delayed surgery group (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001) and a shorter length of hospital stay (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001). There was no significant difference in postoperative mortality and other related indicators.

CONCLUSIONS

Early surgery in hip fracture patients taking clopidogrel and/or aspirin appears to be safe based on the available evidence and needs to be clarified by higher quality studies. However, the increased risk of cardiovascular events associated with discontinuation of clopidogrel or clopidogrel combined with aspirin dual antiplatelet therapy requires attention in the perioperative period.

Association of sex and aspirin use with postoperative bleeding in patients with lower extremity long bone fractures

Objective

The perioperative management of patients on antiplatelet drugs is a rising challenge in orthopedic trauma because antiplatelet drugs are frequently encountered and carry an increased risk of hemorrhagic consequences. The study objective was to examine the effect of aspirin on bleeding outcomes for patients with lower extremity fractures.

Methods

This retrospective study included patients requiring surgical fixation of traumatic hip, femur, and tibia fractures from January 1, 2018, to March 1, 2020. Patients were excluded if they had a significant head injury, were on chronic anticoagulant therapy, or they did not receive venous thromboembolism chemoprophylaxis. Comparisons between aspirin users (patients on aspirin therapy preinjury) and non-aspirin users were examined using χ2 tests, Cochran-Mantel-Haenszel tests, and multivariate logistic regression. The primary outcome was an overt, actionable bleed (eg, blood transfusion for surgical site hemorrhage) within 24 hours postoperative.

Results

There were 864 patients with lower extremity long bone fractures and 24% were aspirin users. The incidence of postoperative bleeding was 8.8% and significantly differed for patients taking aspirin versus not (13.6% vs 7.3%, p=0.01). However, biological sex at birth (M/F) was a significant effect modifier (interaction p=0.04). Among women, there were significantly more postoperative bleeds for aspirin users (17.8% aspirin vs 7.4% no aspirin, adjusted OR (AOR): 2.48 (1.28-4.81), p=0.01). Among men, there were similar postoperative bleeding events by aspirin use (5.6% aspirin vs 7.2% no aspirin, AOR: 0.50 (0.14-1.82), p=0.30). Postoperative hemoglobin values <8 g/dL were more frequent among female aspirin users (21.5% aspirin vs 12.5% no aspirin, p=0.01), but this association was not observed in men (p=0.43).

Conclusion

Women taking aspirin who suffer lower extremity fractures have greater than twofold greater odds of a postoperative bleeding event. These findings suggest adequate perioperative planning to ensure blood availability, and increased awareness to monitor closely for hemorrhage in the 24-hour postoperative window for women taking aspirin preinjury.

Level of evidence

IV.

Retrospective high volume comparative study suggests that patients on aspirin could have immediate surgery for hip fractures without significant blood loss

PURPOSE

This study aimed to investigate the effects of aspirin on peri-operative hidden blood loss during hip fracture surgery by adjusting for possible factors affecting blood loss using a propensity score matching method.

METHODS

We retrospectively collected data from a cohort of isolated hip fracture patients (aged ≥ 65 years)who underwent surgery from January 2010 to December 2019. The study's primary outcome was blood loss from admission to the day after surgery in the aspirin and control groups. We estimated the hidden blood loss, calculated based on patient's blood volume, haemoglobin measurements, and blood transfusions. The secondary outcome focused on the requirement for blood transfusion. We adjusted for possible factors affecting blood loss using a propensity score matching method and statistically examined the effects of aspirin on hip fracture surgery.

RESULTS

We enrolled 806 patients of whom 271 (34%) were taking anticoagulant and antiplatelet drugs, while 114 (14%) were taking only aspirin (aspirin group). A total of 535 patients were not taking antiplatelets and anticoagulants (control group). In propensity score matching, 103 patients were matched. Aspirin was not associated with a significantly higher risk of hidden blood loss (aspirin group; median 598 mL [410-783 mL] vs control group; median 556 ml [321-741 mL], p = 0.14) and higher risk of blood transfusion requirement (aspirin group; 49 patients [48%] vs control group; 39 patients [38%], p = 0.21).

CONCLUSION

Aspirin did not affect peri-operative blood loss in hip fracture surgery. We concluded that patients taking aspirin can safely undergo hip fracture surgery without delay.

Risk factors of perioperative blood transfusion in elderly patients with femoral intertrochanteric fracture

This study aimed to discuss the risk factors of perioperative blood transfusion after the application of proximal femoral nail antirotation (PFNA) in the treatment of elderly patients with femoral intertrochanteric fracture (FIF). Moreover, this study also aimed to analyze the causes of perioperative blood transfusion and provide guidance for clinical treatment.Records of elderly patients with FIF who were treated with PFNA in our hospital from September 2014 to May 2017 were reviewed. They were divided into transfused and nontransfused groups. The Student t test, Chi-squared test, and Fisher exact test were used in univariate analysis of 11 variables. Multivariate logistic regression analysis was performed to analyze the possible risk factors associated with postoperative blood transfusion after the application of PFNA in elderly patients with FIF. Correlations were sought using the Spearman rank correlation analysis.The univariate analysis showed that age, sex, type of fracture, admission hemoglobin (Hb), admission albumin, and intraoperative blood loss were significantly associated with perioperative blood transfusion (P = .000, .019, .000, .000, .000, and .007, respectively). The multivariate logistic regression analysis demonstrated that age (P = .019, odds ratio [OR] = 1.062), type of fracture (P = .001, OR = 4.486), and admission Hb (P = .000, OR = 0.883) were independent risk factors of postoperative blood transfusion. We found a significant positive correlation between perioperative blood transfusion and age (r = 0.264, P = .000) and type of fracture (r = 0.409, P = .000), but a negative correlation between perioperative blood transfusion and admission Hb (r = -0.641, P = .000).The main factors affecting perioperative blood transfusion are age, fracture type, and admission Hb. These results indicate that, in high-risk patients who are older in age, more unstable fractures, and lower admission Hb, monitoring Hb concentrations during the perioperative period is important to correct severe anemia in a timely manner and avoid exacerbating existing underlying diseases and inducing severe complications.

Is hip fracture surgery safe for patients on antiplatelet drugs and is it necessary to delay surgery? A systematic review and meta-analysis

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 Science^TM, 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.

Impact of Antiplatelet Therapies on Patients Outcome in Osteosynthetic Surgery of Proximal Femoral Fractures

BACKGROUND

Proximal femoral fractures should be treated in a timely manner. Affected patients often require antiplatelet therapy (APT) due to cardiovascular diseases. Guidelines recommend 5-7 days APT interruption for elective surgery. Early osteosynthetic surgery of proximal femoral fractures despite of APT should be considered.

AIM OF THE STUDY

To evaluate whether early osteosynthetic surgery despite of APT is associated with increased blood loss, complications and mortality.

METHODS

Data of patients with proximal femoral fractures, who were treated by osteosynthesis at the Department of Trauma Surgery at the Medical University of Vienna were collected retrospectively. Study groups were formed by time to surgery and APT interruption. The primary endpoint of the study was the perioperative blood loss. Secondary endpoints were complications, 30-day and 1-year mortality, time to surgery, and the total length of hospital stay.

RESULTS

The osteosynthetic treatment of proximal femoral fractures despite of APT resulted in a shorter time to surgery (13.8 vs. 66.0 h; p < 0.01). In patients on APT, the TBL (total perioperative blood loss) was higher without need for revision or an increase in the need for packed red blood cells if surgery was performed within 24 h after admission. APT had no significant influence on mortality. Patients who underwent surgery within 24 h after admission had a lower mortality. The complication rate was higher in patients who underwent surgery later than 24 h after admission.

CONCLUSIONS

Surgery within 24 h after admission, regardless of APT, resulted in a shorter hospitalization length and was associated with less common complications and a lower mortality.

The influence of pre-operative antiplatelet and anticoagulant agents on the outcomes in elderly patients undergoing early surgery for hip fracture

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.

Factors affecting blood loss and blood transfusion in patients with proximal humeral fractures

BACKGROUND

The aim of this study was to determine the amount of blood loss and the rate of blood transfusion in patients receiving surgery for proximal humeral fractures depending on the treatment and fracture classification. Moreover, factors associated with blood loss and blood transfusion were analyzed.

METHODS

The study included 420 patients who had received surgery for proximal humeral fractures. Data from medical records were collected retrospectively. The calculated blood loss and the transfusion rate were analyzed depending on the type of surgery (plate fixation, arthroplasty, and others) or the fracture classification (2-, 3-, and 4-part fractures). The extent of blood loss and the need for transfusion were correlated with potential risk factors. A score to estimate the probability of blood transfusion was developed.

RESULTS

Average blood loss was 284 mL, and the transfusion rate was 14.5% for all proximal humeral fractures. Shoulder arthroplasty was associated with higher blood loss (353 mL, P < .01) and a higher blood transfusion rate (27.3%, P < .01) than plate fixation (263 mL and 10.9%, respectively). The fracture classification had no effect on either factor. Significant risk factors for blood loss were male sex, body mass index, surgery time, time until surgery, and vitamin K antagonists. Age, blood loss, American Society of Anesthesiologists score greater than 2, vitamin K antagonists, coronary artery disease (CAD), peripheral artery disease (PAD), and renal disease were associated with a higher transfusion rate.

CONCLUSION

Blood loss could be affected by a shorter surgery time and by choosing an adequate time until surgery. The consideration of risk factors and the use of a transfusion risk score allow more elaborate ordering of cross-matched blood units and can decrease institutional costs.

Does continued aspirin mono-therapy lead to a higher bleeding risk after total knee arthroplasty?

BACKGROUND

Evidence about the risk of bleeding and thromboembolism because of aspirin mono-therapy in total knee arthroplasty (TKA) is scant. We wanted to validate the risks of bleeding and thromboembolism with continued aspirin mono-therapy in unilateral and simultaneous bilateral TKA.

METHODS

We enrolled a series of 1655 patients who underwent unilateral or simultaneous bilateral TKA between December 2010 and December 2012. Drainage amount, postoperative hemoglobin level, change in hemoglobin, calculated blood loss, incidence and the amount of blood transfused, and the proportion of thromboembolic events were compared between patients who were and patients who were not on continued aspirin mono-therapy.

RESULTS

Calculated blood loss (969.1 ± 324.9 vs. 904.0 ± 315.5 ml), transfusion amounts (1.3 ± 1.5 vs. 1.0 ± 1.3 IU), and percentage of transfused patients (53.0% vs. 40.2%) were higher in unilateral TKA patients on continued aspirin mono-therapy. Outcome parameters and the proportion of DVT between groups were not significantly different. One patient (0.3%) not on aspirin mono-therapy developed a pulmonary embolism, and two others (0.6%) had cerebrovascular events.

CONCLUSION

Despite the slightly higher risks of bleeding, continuing aspirin mono-therapy during TKA might be safe with low risks of perioperative cerebrovascular, cardiovascular, and venous thromboembolic events.

Elevated International Normalized Ratio Is Not Associated With Increased Perioperative Morbidity in Podiatric Limb Salvage Surgery: A Retrospective Analysis

The risk of hemorrhage always exists in anticoagulated patients with an elevated international normalized ratio (INR), a risk that must be measured against the necessity for surgical procedures. The objective of the present retrospective medical record study was to assess the safety with which limb salvage procedures can be conducted in patients with an INR >1.4. The medical records of 231 patients who had undergone limb salvage procedures by 1 surgeon at the Yale New Haven Health System from November 2008 through July 2014 were reviewed. All patients were administered foot blocks with monitored intravenous sedation. The patients' demographic data, comorbidities, preoperative anticoagulant use, coagulation profile, intraoperative analgesic administration, estimated blood loss, total operating room time, total postanesthesia care unit time, intraoperative ankle tourniquet use, and postoperative complications within the initial 72 hours were reviewed. We found no differences in intraoperative bleeding, total intraoperative time, or recovery time between the INR <1.4 group (n = 212) and the INR >1.4 group (n = 19). None of the patients experienced any postoperative complications, defined as any cardiac or pulmonary event, the need for invasive monitoring, or admission to the intensive care unit within the initial 72-hour period. Our findings suggest that patients are suitable for undergoing peripheral procedures with foot blocks and monitored intravenous sedation even in the presence of an elevated INR.

Naphthalene, a versatile platform in medicinal chemistry: Sky-high perspective

Naphthalene, a cytotoxic moiety, is an extensively explored aromatic conjugated system with applications in various pathophysiological conditions viz. anticancer, antimicrobial, anti-inflammatory, antiviral, antitubercular, antihypertensive, antidiabetic, anti-neurodegenerative, antipsychotic, anticonvulsant, antidepressant. Naphthalene epoxides and naphthoquinones are most reactive metabolites of naphthalene and are responsible for the covalent interaction with cysteine amino acid of cellular proteins for cytotoxic nature. Many naphthalene derived bioactive phytoconstituents are present in nature including podophyllotoxins (Etoposide, teniposide), bis-ANS 82, Rifampicin, Justiprocumin A, B, Patentiflorin A. The naphthalene-based molecules, viz. Naphyrone, tolnaftate, naftifine, nafcillin, terbinafine, propranolol, nabumetone, nafimidone, naproxen, duloxetine, lasofoxifene, bedaquiline etc. have also been approved by FDA and are being marketed as therapeutics. Thus, the naphthalene scaffold emerges as an important building block in drug discovery owing to its broad spectrum of biological activities through varying structural modifications. This review incorporates the pharmacological aspects of different types of chemically modified naphthalene-based molecules along with their activity profile. This compiled information may serve as a benchmark for the alteration of existing ligands to design novel potent molecules with lesser side effects.

Implications of anticoagulant and antiplatelet therapy in patients presenting with hip fractures: a current concepts review

The increasing use of anticoagulant and antiplatelet therapy for the prevention of thromboembolic disease poses a significant challenge to orthopaedic surgeons treating elderly patients presenting with proximal femoral fractures. Early surgical intervention is known to be beneficial from a clinical perspective and has been encouraged in the UK through the introduction of best practice tariffs providing increased remuneration for prompt treatment. An understanding of the necessary delay to surgery or reversal options for each type of antiplatelet or anticoagulant agent is therefore important. A number of professional bodies have recently produced guidelines that help clinicians manage these patients during the peri-operative period. We review the guidelines relating to antiplatelet and anticoagulant agents during the perioperative period with respect to hip fracture surgery. Antiplatelet agents should not interfere with timing of surgery, but may affect the choice of anaesthetic performed. The action of warfarin should be reversed to expedite surgery. Newer direct oral anticoagulants are more problematic and surgical delay may be necessary, though reversal agents are becoming available.

Preoperative Use of Clopidogrel Does Not Affect Outcomes for Femoral Neck Fractures Treated With Hemiarthroplasty

BACKGROUND

The antiplatelet effect of clopidogrel on blood loss and perioperative complications after surgical intervention remains ambiguous. The purpose of this study was to determine if patients on clopidogrel before hemiarthroplasty for femoral neck fracture are predisposed to greater surgical bleeding and perioperative complications compared with those not taking clopidogrel before surgery.

METHODS

We conducted a review of our electronic medical record from 2006-2013 and identified 602 patients who underwent 623 hemiarthroplasty procedures for displaced femoral neck fracture, of which 54 cases (9%) were taking clopidogrel before hospital admission. Patient demographics and comorbidities, operative and surgical variables, and perioperative complications at 90 days were compared between the clopidogrel and nonclopidogrel user groups.

RESULTS

The 2 groups of patients had similar baseline characteristics, but patients taking clopidogrel preoperatively were sicker with higher American Society of Anesthesiologists scores (P = .049) and age-adjusted Charlson index (P = .001). They also had a greater incidence of cerebrovascular disease (P = .01), chronic obstructive pulmonary disease (P = .03), diabetes (0.03), and malignancy (P < .001). There was no significant difference between the 2 patient groups with respect to 90-day postoperative medical readmissions (P = .85), surgical readmissions (P = .26), infection (P = .99), and mortality (P = .89).

CONCLUSION

Patients taking clopidogrel who present with a displaced femoral neck fracture can safely undergo a hemiarthroplasty while actively on clopidogrel without an increase in medical or surgical complications and mortality. We do not recommend delaying surgical intervention until the antiplatelet effects of clopidogrel subside.

Comparison of preoperative continuation and discontinuation of aspirin in patients undergoing total hip or knee arthroplasty

INTRODUCTION

Preoperative discontinuation of aspirin (acetylsalicylic acid) can reduce bleeding risk but may increase the risk of perioperative cardiovascular events.

MATERIALS AND METHODS

We retrospectively assessed the impact of preoperative continuation versus discontinuation of aspirin compared with a control group in a cohort of 739 consecutive patients undergoing total hip (THA) (n = 396) or knee arthroplasty (TKA) (n = 343) at a tertiary hospital. Bleeding risk, local complications, orthopaedic outcome, and cardiac and cerebral complications were assessed.

RESULTS

Four hundred and sixty-five patients did not receive antithrombotic or full-dose anticoagulant medication, 175 patients were taking low-dose aspirin, 99 vitamin K antagonists, clopidogrel, or a combination of these drugs. Of the patients taking aspirin, 139 discontinued and 36 continued aspirin. Blood loss and local bleeding complications were comparable in these two groups. TKA patients who continued aspirin more frequently showed marked knee swelling after 1 week than those discontinuing aspirin (35.1 vs. 81.3 %; p = 0.001). However, orthopaedic outcome did not differ significantly between the two groups. There was a trend towards an increased risk of cardiac complications in patients who discontinued aspirin (6.5 vs. 0.0 %; p = 0.107).

CONCLUSIONS

Continuation or discontinuation of aspirin did not show a statistically significant difference in the risk of relevant perioperative bleeding complications in our study. Continuation of aspirin was associated with a transitory increase in knee swelling, but had no effect on orthopaedic outcome. Continuation of aspirin may be associated with a favourable perioperative cardiac outcome. Our data support perioperative continuation of aspirin intake in patients undergoing THA or TKA.

Risk factors for the effect of anticoagulant and antiplatelet agents on perioperative blood loss following proximal femoral fractures

To examine the effect of oral anticoagulant and antiplatelet agents on perioperative blood loss following proximal femoral fractures and to identify the risk factors associated with perioperative blood loss.Retrospective cross-sectional study.In a retrospective cross-sectional study, we treated 334 consecutive patients with proximal femoral fractures (100 who received anticoagulant or antiplatelet drugs and 234 who did not) and an overall mean age of 85.5 years (standard deviation 8.2 years). We performed retrospective multivariate analysis to determine the independent factors related to perioperative decreases in the hemoglobin (Hb) level, a proxy for blood loss.Multivariate analysis confirmed that anticoagulant or antiplatelet drugs significantly affected decreases in the Hb level (regression coefficient [RC], 0.61; 95% confidence interval [CI], 0.14-1.08; P = 0.01). In addition to anticoagulant or antiplatelet drugs, multivariate analysis confirmed that the fracture type (Orthopedic Trauma Association classification A2: RC, 1.19; 95% CI, 0.71-1.67; P < 0.01; A3: RC, 2.47; 95% CI, 1.41-3.53; P < 0.01), platelet count (RC, -0.08; 95% CI, -0.12 to -0.04; P < 0.01), and operative time (RC, 0.02; 95% CI, 0.004-0.03; P = 0.01) affected the decreases in Hb level.The use of anticoagulants and antiplatelet agents is an independent risk factor for perioperative blood loss following proximal femoral fractures. Fracture type, platelet count, and operative time also affect perioperative blood loss. The fracture type was the greatest contributing factor to perioperative blood loss.Level of evidence grade: Prognostic level III.

Clopidogrel and hip fractures, is it safe? A systematic review and meta-analysis

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.

Effect of early surgery in high surgical risk geriatric patients with femoral neck fracture and taking antiplatelet agents

AIM: To investigate the effect of early surgical intervention on the high surgical risk elderly patients who sustained femoral neck fracture (FNF) and taking concomitant antiplatelet agents.

METHODS: Between 2010 and 2012, a prospective study was conducted on 49 geriatric patients, who took antiplatelet agents, sustained FNF and underwent surgery within 72 h [early surgery (ES) group], and these were compared with a retrospective consecutive case series of patients with similar characteristics (45 cases) who had delayed surgery (DS group) after 72 h during an earlier 3-year period. Postoperative outcomes were followed for one year and compared.

RESULTS: There were non-significant differences in perioperative blood loss, blood transfusion, intensive care unit requirement and postoperative mortality (P > 0.05 all). There were 2 patients (4%) in the DS group who died after surgery (P = 0.23). However, the ES group showed a significantly better postoperative outcome in terms of postoperative complications, length of hospital stay, and functional outcome (P < 0.05 all).

CONCLUSION: Early hip surgery in geriatric hip fracture patients with ongoing antiplatelet treatment was not associated with a significant increase of perioperative blood loss and postoperative mortality. Moreover, ES resulted in a better postoperative surgical outcome. In early hip surgery protocol, the antiplatelet agents are discontinued and the patient is operated on within 72 h after admission, which is safe and effective for the medically fit patients.

Perioperative Treatment of Patients with Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease mediated by a widespread chronic systematic inflammatory process that causes joint deterioration, which leads to pain, disability, and poor quality of life. The increased use of disease-modifying antirheumatic drugs has been shown to markedly slow disease progression, which has translated into a decrease in the need for orthopaedic intervention in this population. However, a substantial percentage of patients with the disease fail optimal pharmacologic treatment and still require surgical intervention. A thorough understanding of medical considerations in these patients and improved knowledge of the medical complications caused by the disease process and the pharmacologic therapy used to treat it may lead to improved preoperative planning and medical clearance, which may ultimately improve the overall postoperative outcome.

Fentanyl buccal tablet versus oral oxycodone for Emergency Department treatment of musculoskeletal pain

Background: Emergency Department (ED) analgesia can potentially be delivered quickly using transbuccal administration. A previous study identified time-of-onset advantage of a 100 mcg fentanyl buccal tablet (FBT) as compared to a dose of 5 mg oxycodone with 325 mg acetaminophen. The current study reports comparison of higher-dose (200 mcg) FBT as compared to a more commonly used oxycodone dose of 10 mg with 650 mg acetaminophen. Methods: Time frame: Patients were enrolled between October 2012 and October 2014.

Setting: The study was conducted in an urban teaching ED with annual census of 55,000.

Patients: The 50 convenience-sampled cases met eligibility criteria of age 18-60, with isolated orthopedic complaints; subjects required X-ray to rule-out fracture, and to have pain sufficient to warrant opioids.

Interventions: In this double-blind placebo-controlled analgesia trial, patients were randomized to one of two study groups. OXY subjects received two orally ingested tablets, each containing 5 mg oxycodone and 325 mg acetaminophen, and a transbuccal inactive comparator. FBT subjects received two placebo oral tablets and a 200 mcg FBT.

Data: The main study endpoint was achievement of at least two points' reduction in numeric pain rating scale (NPRS) within ten minutes of study drug administration. NPRS was assessed at the time of study entry and every five minutes' post-drug administration for an hour. Secondary endpoints included assessment of side effects and subjects' desire to have the same medication for future similar pain.

Analysis: Categorical data were assessed with binomial exact 95% confidence intervals (CIs). Continuous data, after being demonstrated as non-normal with skewness-kurtosis testing, were analyzed with Kruskal-Wallis testing. Multivariate Cox proportional hazards analysis was performed to assess whether, after adjustment for potential confounders, there was a difference between FBT and OXY groups with respect to time to achieving significant analgesia. Results: Study groups were similar with respect to age (medians: OXY 34, FBT 38, p = 0.47), initial pain score (median 8 in each group), sex (proportion of males: OXY 64%, FBT 48%, p = 0.25), and ethnicity (proportion of whites: OXY 68%, FBT 56%, p = 0.38). The same proportion (52%) of OXY and FBT cases achieved significant reduction in pain within 15 minutes. Multivariate Cox regression adjusting for potential confounders confirmed (p = 0.28) no difference in rates of pain reduction between OXY and FBT. There were no major complications in either group. The majority of subjects in each group (80% in FBT group versus 76% in OXY group, p = 0.73) expressed high satisfaction and preference to receive the same regimen in future. Conclusion: This study's results suggest approximate equivalence between 200 mcg FBT and 10 mg oxycodone with 650 mg acetaminophen, with respect to time-to-analgesia, analgesic efficacy, side effects, and patient satisfaction.

Traumax screw plate vs. Gamma nail. Blood loss in pertrochanteric fractures treated by minimally invasive osteosynthesis

PURPOSE

This study is aimed to determine whether the Traumax dynamic hip screw reduces perioperative blood loss and transfusion rate compared to the Gamma nail in the treatment of pertrochanteric fractures.

MATERIALS AND METHODS

A series of 331 patients were followed prospectively in a cohort study between February 2008 and October 2011 after a pertrochanteric fracture. Two types of fixation were used, 163 patients were treated with a Gamma nail and 168 patients with a minimally invasive screw plate Traumax. Perioperative blood loss, evaluated by the Mercuriali formula based on pre- and postoperative haemoglobin and transfusion rates were compared in order to assess risk factors.

RESULTS

Increased perioperative blood loss was significantly linked with patient-related parameters (age, anticoagulant and platelet aggregation inhibitor treatment). Type of osteosynthesis and type of fracture were also risk factors for blood loss and transfusion. The Traumax group had significantly lower blood loss (347 ml vs. 577 ml) and transfusion rate (33.9% vs. 63.8%) than the Gamma group. Involvement of the greater trochanter increased the risk of blood loss only in the Gamma group. Functional results and bone healing were comparable at six months follow-up.

CONCLUSION

Screw plate Traumax significantly reduces perioperative bleeding after pertrochanteric fractures. It avoids fracture gaps that tend to maintain bleeding. Given the morbidity and complications related to acute anaemia and blood transfusion, the surgical management of these elderly patients is aided by this choice of fixation.

Preoperative factors associated with red blood cell transfusion in hip fracture patients

INTRODUCTION

Red blood cell (RBC) transfusion is a frequently used treatment in patients admitted with a fractured hip, but the use remains an area of much debate. The aim of this study was to determine preoperative factors associated with the risk of receiving a red blood cell transfusion in hip fracture patients.

METHOD

The study included 986 consecutive hip fracture patients (aged 60 years or above). The patients were identified from a database of all hip fracture patients admitted to Bispebjerg University Hospital. Data for the database are collected via chart review and data extraction from the hospitals laboratory system, public registries and from the Capital Region Blood Bank Database.

RESULTS

Overall transfusion rate was 58.7 %. The univariate analyses showed that transfusion rate was higher among women (p = 0.004), older patients (p < 0.0001), patients with high ASA scores (p < 0.0001), patients with more severe fractures (p < 0.0001), patients with lower admission haemoglobin levels (p < 0.0001), patients not admitted from own home (p = 0.02) and patients taking aspirin (p = 0.007) or other platelet inhibitors (p = 0.01) on admission. In the multivariate analysis, increasing age, ASA ≥3, being admitted from own home, extracapsular fractures, decreasing admission haemoglobin and use of platelet inhibitors were all significantly associated with the risk of receiving a RBC transfusion.

CONCLUSION

Several readily available preoperative factors in the form of age, residence, ASA, admission haemoglobin, medication and type of fracture were independently associated with the likelihood of receiving a red blood cell transfusion in patients admitted with a fractured hip.

Perioperative management of antiplatelet therapy

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.

The impact of antiplatelet medication on hand and wrist surgery

PURPOSE

To quantify the impact of maintaining antiplatelet medication during hand and wrist surgery on bleeding and functional outcomes.

METHODS

This prospective cohort trial compared operative outcomes and complications of hand and wrist surgery in patients without interruption of daily antiplatelet medications (n = 107 procedures) with control patients (n = 107 procedures). We determined rates of complications requiring reoperation for each group. We compared measures of surgical site bleeding (extent of ecchymosis or hematoma formation), patient-rated outcome assessment (Quick Disabilities of the Arm, Shoulder, and Hand score and visual analog scales of pain and swelling), and 2-point discrimination between groups. Data were collected preoperatively and postoperatively at 2 and 4 weeks. We confirmed control and antiplatelet populations to be similar for data analysis according to health status (Short Form-12) and percentage of bony procedures.

RESULTS

One patient receiving antiplatelet medication required reoperation for surgical site bleeding after wrist arthrodesis (0.9%). There were no complications in the control group. The extent of postoperative ecchymosis was similar in the antiplatelet and control patients at 2 weeks (16 vs 19 mm) and 4 weeks (1 vs 1 mm). Hematoma rates were not increased for patients receiving antiplatelet medication (17% vs 14% at 2 wk). Patient-rated function scores were equivalent at baseline and at follow-up between groups. A total of 22 control patients and 20 patients receiving antiplatelet medication had transiently increased 2-point discrimination (≥ 2-mm change) postoperatively.

CONCLUSIONS

Bleeding-related perioperative complications were rare when continuing antiplatelet medications without interruption for hand and wrist surgery. Maintenance of antiplatelet medication does not appear to negatively affect patient-rated or objective measures of function, although surgical-site bleeding may be greatest in patients taking higher-dose antiplatelet medication and undergoing bony procedures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Should more patients continue aspirin therapy perioperatively?: clinical impact of aspirin withdrawal syndrome

OBJECTIVE

To provide an evidence-based focused review of aspirin use in the perioperative period along with an in-depth discussion of the considerations and risks associated with its preoperative withdrawal.

BACKGROUND

For patients with established cardiovascular disease, taking aspirin is considered a critical therapy. The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events. Despite the risks of aspirin withdrawal, which are exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding. Mounting evidence suggests that this practice should be abandoned.

METHODS

We performed a PubMed and Medline literature search using the keywords aspirin, withdrawal, and perioperative. We manually reviewed relevant citations for inclusion.

RESULTS/CONCLUSIONS

Clinicians should employ a patient-specific strategy for perioperative aspirin management that weighs the risks of stopping aspirin with those associated with its continuation. Most patients, especially those taking aspirin for secondary cardiovascular prevention, should have their aspirin continued throughout the perioperative period. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. For many operative procedures, the risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal. Those cases where aspirin should be stopped include patients undergoing intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.

[Low-dose aspirin doesn't increase surgical bleeding nor transfusion rate in total knee arthroplasty]

OBJECTIVES

Surgical bleeding. transfusion rate and cardiovascular complications were analized in patients undergoing chronic treatment with low-doses aspirin and scheduled to unilateral primary knee arthroplasty.

PATIENTS AND METHODS

We retrospectively studied 117 patients between 2005 and 2006 scheduled for elective knee replacement that received antiplatelet therapy with aspirin (100mg/day). Aspirin medication was maintained or discontinued preoperatively according to medical criteria. We analyzed the biological, clinical and anesthetic data, blood-saving techniques used, surgical bleeding, allogeneic blood transfusion rate, cardiocirculatory complications (myocardial, cerebral or peripheral ischemia), hospital stay and mortality. This population was compared with 190 patients (control group) who underwent the same operation at the same time interval but did not receive aspirin therapy.

RESULTS

The aspirin-treated group was significantly older, with higher weight and poorer health state (higher incidence of ischemic heart disease, cerebral ischemia and diabetes). The hidden and external surgical bleeding and transfusion rate were similar if the aspirin were interrupted or not, preoperatively. Bleeding and transfusion rates were independent of time of interruption of the aspirin. Hospital mortality was zero in the 2 groups. A acute myocardial infarction and a transient stroke happened in two patients wich aspirin treatment was discontinued.

CONCLUSIONS

Preoperative treatment with low doses of aspirin does not increase surgical bleeding and transfusion rate in total knee arthroplasty. Preoperative discontinuation can cause severe cardiocirculatory complications.

Bleeding and first-year mortality following hip fracture surgery and preoperative use of low-dose acetylsalicylic acid: an observational cohort study

Background

Hip fracture is associated with high mortality. Cardiovascular disease and other comorbidities requiring long-term anticoagulant medication are common in these mostly elderly patients. The objective of our observational cohort study of patients undergoing surgery for hip fracture was to study the association between preoperative use of low-dose acetylsalicylic acid (LdAA) and intraoperative blood loss, blood transfusion and first-year all-cause mortality.

Methods

An observational cohort study was conducted on patients with hip fracture (cervical requiring hemiarthroplasty or pertrochanteric or subtrochanteric requiring internal fixation) participating in a randomized trial that found lack of efficacy of a compression bandage in reducing postoperative bleeding. The participants were 255 patients (≥50 years) of whom 118 (46%) were using LdAA (defined as ≤320 mg daily) preoperatively. Bleeding variables in patients with and without LdAA treatment at time of fracture were measured and blood transfusions given were compared using logistic regression. The association between first-year mortality and preoperative use of LdAA was analyzed with Cox regression adjusting for age, sex, type of fracture, baseline renal dysfunction and baseline cardiovascular and/or cerebrovascular disease.

Results

Blood transfusions were given postoperatively to 74 (62.7%) LdAA-treated and 76 (54%) non-treated patients; the adjusted odds ratio was 1.8 (95% CI 1.04 to 3.3). First-year mortality was significantly higher in LdAA-treated patients; the adjusted hazard ratio (HR) was 2.35 (95% CI 1.23 to 4.49). The mortality was also higher with baseline cardiovascular and/or cerebrovascular disease, adjusted HR 2.78 (95% CI 1.31 to 5.88). Patients treated with LdAA preoperatively were significantly more likely to suffer thromboembolic events (5.7% vs. 0.7%, P = 0.03).

Conclusions

In patients with hip fracture (cervical treated with hemiarthroplasty or pertrochanteric or subtrochanteric treated with internal fixation) preoperative use of low-dose acetylsalicylic acid was associated with significantly increased need for postoperative blood transfusions and significantly higher all-cause mortality during one year after surgery.

A randomised controlled pilot trial to evaluate and optimize the use of anti-platelet agents in the perioperative management in patients undergoing general and abdominal surgery--the APAP trial (ISRCTN45810007)

PURPOSE

Surgeons are increasingly confronted by patients on long-term low-dose acetylsalicylic acid (ASA). However, owing to a lack of evidence-based data, a widely accepted consensus on the perioperative management of these patients in the setting of non-cardiac surgery has not yet been reached. Primary objective was to evaluate the safety of continuous versus discontinuous use of ASA in the perioperative period in elective general or abdominal surgery.

METHODS

Fifty-two patients undergoing elective cholecystectomy, inguinal hernia repair or colonic/colorectal surgery were recruited to this pilot study. According to cardiological evaluation, non-high-risk patients who were on long-term treatment with low-dose ASA were eligible for inclusion. Patients were allocated randomly to continuous use of ASA or discontinuation of ASA intake for 5 days before until 5 days after surgery. The primary outcome was the incidence of major haemorrhagic and thromboembolic complications within 30 days after surgery.

RESULTS

A total of 26 patients were allocated to each study group. One patient (3.8%) in the ASA continuation group required re-operation due to post-operative haemorrhage. In neither study group, further bleeding complications occurred. No clinically apparent thromboembolic events were reported in the ASA continuation and the ASA discontinuation group. Furthermore, there were no significant differences between both study groups in the secondary endpoints.

CONCLUSIONS

Perioperative intake of ASA does not seem to influence the incidence of severe bleeding in non-high-risk patients undergoing elective general or abdominal surgery. Further, adequately powered trials are required to confirm the findings of this study.

The effect of clopidogrel and aspirin on blood loss in hip fracture surgery

INTRODUCTION

Anti-platelet drugs are commonly used for primary and secondary prevention of thrombo-embolic events and following invasive coronary interventions. Their effect on surgery-related blood loss and perioperative complications is unclear, and the management of trauma patients treated by anti-platelets is controversial. The anti-platelet effect is over in nearly 10 days. Notably, delay of surgical intervention for hip fracture repair for >48 h has been reported to increase perioperative complications and mortality.

PATIENTS AND METHODS

Intra-operative and perioperative blood loss, the amount of transfused blood and surgery-related complications of 44 patients on uninterrupted clopidogrel treatment were compared with 44 matched controls not on clopidogrel (either on aspirin alone or not on any anti-platelets).

RESULTS

The mean perioperative blood loss was 899±496 ml for patients not on clopidogrel, 1091±654 ml for patients on clopidogrel (p=0.005) and 1312±686 ml for those on combined clopidogrel and aspirin (p=0.0003 vs. all others). Increased blood loss was also associated with a shorter time to operation (p=0.0012) and prolonged surgical time (p=0.0002). There were no cases of mortality in the early postoperative period.

CONCLUSIONS

Patients receiving anti-platelet drugs can safely undergo hip fracture surgery without delay, regardless of greater perioperative blood loss and possible thrombo-embolic/postoperative bleeding events.

Precordial steering wheel: a fortunate accident

BACKGROUND

Myocardial ischemia has been associated with motor vehicle collisions (MVCs). However, we were unable to find reported cases of ST-segment elevation myocardial infarction (STEMI) leading to ventricular tachyarrhythmia and subsequent MVC. In such patients, decisions regarding antiplatelet and antithrombotic therapy need to balance the risk of ongoing myocardial ischemia and hemorrhage.

OBJECTIVES

To describe a case of STEMI and ventricular fibrillation (VF) associated with a head-on MVC, and to describe the management decisions involved in the care of such a patient.

CASE REPORT

A 47-year-old man presented to the Emergency Department after a single-car head-on collision with a wall at high speed. He had a facial degloving injury as well as right-sided flail chest. An electrocardiogram demonstrated ST-segment elevation in the inferior and anterior leads. Due to the patient's significant traumatic injuries, he underwent a rapid trauma evaluation and was transferred for emergent cardiac catheterization, which demonstrated evidence of plaque rupture in the right coronary artery (RCA). Flow distal to the lesion was preserved, so stent implantation was initially deferred out of concern for hemorrhage secondary to the aggressive antiplatelet and antithrombotic regimen requisite with stent implantation. The patient then went into VF in the cardiac catheterization laboratory, and repeat angiography demonstrated an occluded RCA, and the patient underwent successful stent implantation.

CONCLUSION

The management of STEMI in the setting of trauma is complex. Pharmacologic agents used in STEMI increase the risk of bleeding, and management must balance the risk of prolonged ischemia with the risk of hemorrhage.

The impact of antiplatelet therapy on pelvic fracture outcomes

INTRODUCTION

Despite increasing use of antiplatelet agents (APA), little is known regarding the effect of these agents on the orthopedic trauma patient. This study reviews clinical outcomes of patients with pelvic fractures (Pfx) who were using pre-injury APA. Specifically, we focused on the influence of APA on postinjury bleeding, transfusions, and outcomes after Pfx.

METHODS

Patients with Pfx admitted during a 37-month period beginning January 2006 were divided into APA and non-APA groups. Pelvic injuries were graded using pelvic fracture severity score (PFSS)-a combination of Young-Burgess (pelvic ring), Letournel-Judet (acetabular), and Denis (sacral fracture) classifications. Other clinical data included demographics, co-morbid conditions, medications, injury severity score (ISS), associated injuries, morbidity/mortality, hemoglobin trends, blood product use, imaging studies, procedures, and resource utilization. Multivariate analyses for predictors of early/late transfusions, pelvic surgery, and mortality were performed.

RESULTS

A total of 109 patients >45 years with Pfx were identified, with 37 using preinjury APA (29 on aspirin [ASA], 8 on clopidogrel, 5 on high-dose/scheduled non-steroidal anti-inflammatory agents [NSAID], and 8 using >1 APAs). Patients in the APA groups were older than patients in the non-APA group (70 vs. 63 years, P < 0.01). The two groups were similar in gender distribution, PFSS and ISS. Patients in the APA group had more comorbidities, lower hemoglobin levels at 24 h, and received more packed red blood cell (PRBC) transfusions during the first 24 h of hospitalization (all, P < 0.05). There were no differences in platelet or late (>24 h) PRBC transfusions, blood loss/transfusions during pelvic surgery, lengths of stay, post-ED/discharge disposition, or mortality. In multivariate analysis, predictors of early PRBC transfusion included higher ISS/PFSS, pre-injury ASA use, and lower admission hemoglobin (all, P < 0.03). Predictors of late PRBC transfusion included the number of complications, gender, PFSS, and any APA use (all, P < 0.05). Mortality was associated with pelvic hematoma/contrast extravasation on imaging, number of complications, and higher PFSS/ISS (all, P < 0.04).

CONCLUSIONS

Results of this study support the contention that preinjury use of APA does not independently affect morbidity or mortality in trauma patients with Pfx. Despite no clinically significant difference in early postinjury blood loss, pre-injury use of APA was associated with increased likelihood of receiving PRBC transfusion within 24 h of admission. Furthermore, multivariate analyses demonstrated that among different APA, only preinjury ASA (vs. clopidogrel or NSAID) was associated with early PRBC transfusions. Late transfusion was associated with the use of any APA, complications, higher PFSS, and need for pelvic surgery.

Influence of timing and oral anticoagulant/antiplatelet therapy on outcomes of patients affected by hip fractures

BACKGROUND

Patients undergoing surgical procedures are usually asked to discontinue any anticoagulant/antiplatelet therapy and delay surgery for at least 5 days to reduce the risk of major bleeding and spinal hematoma.

AIM

The purpose of this study was to determine if this strategy is suitable for patients on anticoagulant/antiplatelet therapy affected by a hip fracture, evaluating the effect of anticoagulant/antiplatelet therapy and surgical timing on mortality and complication rates for patients affected by a hip fracture.

PATIENTS AND METHODS

We performed an observational study on patients referring to our hospital for a hip fracture. We evaluated patients on warfarin, ticlopidine, and aspirin therapy matched to patients not on anticoagulant or antiplatelet therapy, out of 875 consecutive patients treated for a hip fracture in a 5-year period. Blood loss, blood transfusions, length of hospitalization, walking ability, complications, and mortality at 1 year of follow-up were recorded. Kruskal-Wallis, Mann-Whitney U, and logistic regression statistical tests were performed.

RESULTS

Patients on warfarin therapy operated more than 5 days after admission showed significantly higher complication and mortality rates compared to all other patients. Two critical factors were identified: warfarin therapy and excessive time to surgery; these factors are not significant if taken alone, while they become a high-risk factor if taken together.

CONCLUSION

The "discontinue drug, and delay surgery" strategy is not suitable for patients on anticoagulant (warfarin) therapy affected by a hip fracture.

A review of the use of common antiplatelet agents in orthopaedic practice

Antiplatelet agents are widely prescribed for the primary and secondary prevention of cardiovascular events. A common clinical problem facing orthopaedic and trauma surgeons is how to manage patients receiving these agents who require surgery, either electively or following trauma. The dilemma is to balance the risk of increased blood loss if the antiplatelet agents are continued peri-operatively against the risk of coronary artery/stent thrombosis and/or other vascular event if the drugs are stopped. The traditional approach of stopping these medications up to two weeks before surgery appears to pose significant danger to patients and may require review. This paper covers the important aspects regarding the two most commonly prescribed antiplatelet agents, aspirin and clopidogrel.

Perioperative handling of patients on antiplatelet therapy with need for surgery

The widespread use of metal stents and drug-eluting stents has shown the extent to which patients with unstable coronary perfusion depend on antiplatelet drugs, and how their risk of late thrombosis depends on the long-term use of agents such as clopidogrel. It has also been shown that the risk of surgical bleeding, if antiplatelet drugs are continued, is lower than that of coronary thrombosis if they are withdrawn. Thus, except for low-risk settings, the practice of withdrawing antiplatelet drugs 5-10 days prior to surgical procedures should be changed. The following suggestions are meant to provide a guideline in this respect. Most of the current surgical procedures may be performed while on low-dose aspirin treatment. Except when bleeding may occur in closed spaces (e.g. intracranial surgery, spinal surgery in the medullary canal, surgery of the posterior chamber of the eye) or where excessive blood loss is expected, where only clopidogrel should be discontinued; in all other cases the surgical procedures should be carried out in the presence of dual antiplatelet agents (if prescribed). Aspirin may be discontinued only in subjects at low risk of thrombosis, and at high risk of intraoperative bleeding. Operations associated with an expected excessive blood loss should be postponed unless vital. When prescribed for acute coronary syndrome or during stent re-endothelialization, clopidogrel should not be discontinued before a noncardiac procedure. For elective procedures, surgery should be postponed until the end of the indication for clopidogrel. After the operation, clopidogrel should be resumed within the 12-24 h. Cardiac procedures should be postponed for at least 4 days after clopidogrel withdrawal. The thrombotic risk of preoperative withdrawal of antiplatelet drugs overwhelms the benefit of regional or neuraxial blockade. Antiplatelet treatment replacement by heparin or low-molecular weight heparin does not provide protection against the risk of coronary artery or stent thrombosis. Haemostasis requires that at least 20% of circulating platelets have a normal function. As the effects of antiplatelet agents are not reversible by other drugs, fresh platelets are the only manner to rapidly restore normal haemostasis. Aprotinin decreases postoperative bleeding and transfusion rates in patients undergoing CABG and on clopidogrel during the days preceding surgery.

Lack of Complications in Minor Skin Lesion Excisions in Patients Taking Aspirin or Warfarin Products

Many patients undergoing surgical procedures take medications that influence the coagulation system. It is common practice to discontinue the use of aspirin and warfarin products 7 to 10 days before any major surgical procedure. However, there is some controversy as to whether these medications should be discontinued for minor dermatological procedures. Our aim was to study the incidence of complications in patients receiving aspirin or warfarin and undergoing minor dermatological procedures. Two thousand three hundred twenty-six patients, operated on by a single surgeon, were studied for complications. Warfarin was used by 28 patients, 228 took aspirin, and the remainder took neither. There was no difference in the complication rate among the three groups as long as the surgeon diligently obtained hemostasis. It appears that patients taking aspirin or warfarin do not need to discontinue these medications before minor dermatological procedures.

Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction

Recent clinical data show that the risk of coronary thrombosis after antiplatelet drugs withdrawal is much higher than that of surgical bleeding if they are continued. In secondary prevention, aspirin is a lifelong therapy and should never be stopped. Clopidogrel is regarded as mandatory until the coronary stents are fully endothelialized, which takes 3 months for bare metal stents, but up to 1 yr for drug-eluting stents. Therefore, interruption of antiplatelet therapy 10 days before surgery should be revised. After reviewing the data on the use of antiplatelet drugs in cardiology and in surgery, we propose an algorithm for the management of patients, based on the risk of myocardial ischaemia and death compared with that of bleeding, for different types of surgery. Even if large prospective studies with a high degree of evidence are still lacking on different antiplatelet regimens during non-cardiac surgery, we propose that, apart from low coronary risk situations, patients on antiplatelet drugs should continue their treatment throughout surgery, except when bleeding might occur in a closed space. A therapeutic bridge with shorter-acting antiplatelet drugs may be considered.

Perioperative use of anti-platelet drugs

Performing a surgical procedure on a patient undergoing anti-platelet therapy raises a dilemma: is it safer to withdraw the drugs and reduce the haemorrhagic risk, or to maintain them and reduce the risk of myocardial ischaemic events? Based on recent clinical data, this review concludes that the risk of coronary thrombosis on anti-platelet drugs withdrawal is much higher than the risk of surgical bleeding when maintaining them. In secondary prevention, aspirin is a lifelong therapy and should never be stopped. Clopidogrel is mandatory as long as the coronary stents are not fully endothelialized, which takes 6-24 weeks depending on the technique used, but might be required for a longer period.

Discontinuation of perioperative antiplatelet and anticoagulant therapy in stroke patients

Growing evidence suggests that perioperative withdrawal of ASA for secondary stroke prevention increases thromboembolic risk without the associated benefit of decreased bleeding complications. ASA maintenance is acceptable in many procedures, including invasive ones. Many procedures, in particular ophthalmologic, dermatologic, and dental surgeries, also are safe while continuing oral AC. Warfarin has been continued successfully even in some surgeries that have high bleeding risk. When the risk is too high, temporary bridging therapy with LWMH is safe in many populations. Although the exact thromboembolic risks associated with temporary cessation of AP and AC are unknown and likely low, morbidity and mortality associated with thromboembolism are high. Further studies investigating the risks and benefits of maintaining AP and AC during procedures, particularly invasive ones, are needed. Meanwhile, it is critical that physicians understand the risks and benefits of perioperative AP and AC and the variety of procedures in which these agents can be safely continued.