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Xiao J, Xie Y, Liu J, Liu T, Ye R, Duan X, Le Z, Deng N, Duan Q. Assessing Mailuoning injection in wound healing and thrombophlebitis management: A rat model study. Int Wound J 2024; 21:e14527. [PMID: 38095110 PMCID: PMC10961041 DOI: 10.1111/iwj.14527] [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: 11/05/2023] [Revised: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 03/25/2024] Open
Abstract
Thrombophlebitis is the inflammatory condition characterized by obstruction of one or more vessels, commonly in the legs, due to the formation of blood clots. It has been reported that traditional Chinese medicine, including Mailuoning injection, is advantageous for treating inflammatory and blood disorders. This research assessed the therapeutic efficacy of Mailuoning injection in the treatment of thrombophlebitis in rodents, as well as investigated its impact on fibrinolysis, inflammation, and coagulation. An experimental setup for thrombophlebitis was established in rodents via modified ligation technique. Five groups comprised the animals: sham operation group, model group, and three Mailuoning treatment groups (low, medium, and high dosages). The pain response, edema, coagulation parameters (PT, APTT, TT, FIB), serum inflammatory markers (IL-6, TNF-α, CRP), and expression levels of endothelial markers (ICAM-1, VCAM-1, NF-κB) were evaluated. Blood flow and vascular function were further assessed by measuring hemorheological parameters and the concentrations of TXB2, ET, and 6-k-PGF1α. In contrast to the sham group, model group demonstrated statistically significant increases in endothelial expression levels, coagulation latencies, and inflammatory markers (p < 0.05). The administration of mailing, specifically at high and medium dosages, resulted in a substantial reduction in inflammatory markers, enhancement of coagulation parameters, suppression of ICAM-1 and VCAM-1 expression, and restoration of hemorheological measurements to baseline (p < 0.05). Significantly higher concentrations of 6-k-PGF1α and lower levels of TXB2 and ET were observed in high-dose group, suggesting that pro- and anti-thrombotic factors were restored to equilibrium. Utilization of Mailuoning injection in rat model of thrombophlebitis exhibited significant therapeutic impact. This effect was manifested through pain alleviation, diminished inflammation, enhanced blood viscosity and facilitation of fibrinolysis. The study indicated that Mailuoning injection may serve as a viable therapeutic option for thrombophlebitis, potentially aiding in the improvement of wound healing by virtue of its anti-inflammatory and blood flow-enhancing characteristics.
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Affiliation(s)
- Junqi Xiao
- Department of Vascular SurgeryThe First Affiliated Hospital of Gannan Medical UniversityGanzhouChina
| | - Yang Xie
- Department of Thyroid Surgerythe First Affiliated Hospital of Gannan Medical CollegeGanzhouChina
| | - Jianping Liu
- Department of Vascular SurgeryThe First Affiliated Hospital of Gannan Medical UniversityGanzhouChina
| | - Tao Liu
- Medical Big Data CenterThe First Affiliated Hospital of Gannan Medical CollegeGanzhouChina
| | - Rong Ye
- Department of Vascular SurgeryThe First Affiliated Hospital of Gannan Medical UniversityGanzhouChina
| | - Xunhong Duan
- Department of Vascular SurgeryThe First Affiliated Hospital of Gannan Medical UniversityGanzhouChina
| | - Zhibiao Le
- Department of Vascular SurgeryThe First Affiliated Hospital of Gannan Medical UniversityGanzhouChina
| | - Nan Deng
- Department of Vascular SurgeryThe First Affiliated Hospital of Gannan Medical UniversityGanzhouChina
| | - Qing Duan
- Department of Vascular SurgeryThe First Affiliated Hospital of Gannan Medical UniversityGanzhouChina
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Gallagher N, Berger J, Jones HB, Lloyd CJ. Frailty as an indicator of postoperative complications following surgical excision of non-melanoma skin cancer on the head and neck. Ann R Coll Surg Engl 2023; 105:342-347. [PMID: 35950511 PMCID: PMC10066642 DOI: 10.1308/rcsann.2022.0067] [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] [Accepted: 05/03/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Non-melanoma skin cancer (NMSC) predominantly affects those aged over 90 years, with 85% of lesions arising on the head and neck, where surgical excision remains the treatment of choice. Frailty is a measure of physiologic age and can be used as a predictor of adverse treatment outcomes. The aim of this study was to determine if the Rockwood Frailty Index is predictive of complications following excision of NMSC. METHODS Data were collected prospectively for patients who underwent an excision of a suspected NMSC from the head or neck across a two-month period. Details of the patient, lesion and procedure were recorded alongside ASA grade and Rockwood's Frailty score. Postoperative complications were recorded four weeks later. RESULTS There was a total of 125 patients: 74 (60%) male, 51 (40%) female; mean age was 78 (±9.8) years. Of the excised sites, 61% were closed primarily, 26% with a full thickness skin graft (FTSG), 13% with a local flap. Frailty ranged from 1 to 7 (median = 4). ASA ranged from 1 to 4 (median = 3). A total of 21 (17%) patients reported postoperative complications. Within this group, the median frailty and ASA grades were 5 and 3. Both frailty and ASA were positively significantly associated with age (p ≤ 0.001). There was no significant difference between the frailty or ASA grades of patients that experienced complications and those who did not. Patients who had a FTSG were significantly more likely to experience complications (p ≤ 0.05). CONCLUSIONS Frailty is not predictive of postoperative complications following excision of NMSC on the head and neck. Postoperative complications are significantly more associated with FTSG.
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Affiliation(s)
| | - J Berger
- Betsi Cadwaladr University Health Board, UK
| | - HB Jones
- Betsi Cadwaladr University Health Board, UK
| | - CJ Lloyd
- Betsi Cadwaladr University Health Board, UK
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Hazkani I, Billings KR, Edwards E, Stein E, Bhat R, Lavin J. Perioperative management in chronically anticoagulated children undergoing tonsillectomy. Pediatr Int 2023; 65:e15438. [PMID: 36504262 DOI: 10.1111/ped.15438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 12/07/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND When undergoing tonsillectomy, patients at high risk of thrombosis who require chronic anticoagulation therapy pose a special challenge as bleeding may occur up to 2 weeks after surgery. Because of a lack of evidence-based data, there is no consensus on the best management for such patients. The objective of our study was to review perioperative anticoagulation bridging strategies in children undergoing tonsillectomy. METHODS The study group were a retrospective series of patients on chronic anticoagulation therapy at high risk of a thromboembolic event, who underwent tonsillectomy from 2010 to 2021. Patients whose anticoagulation treatment was discontinued because of a low risk of thromboembolic events were excluded. RESULTS Four patients met the inclusion criteria (age range, 1.5-16.1 years). All patients were admitted prior to surgery for bridging therapy with intravenous unfractionated heparin (UFH), drip-titrated to a therapeutic dose until 4-6 h prior to surgery. The estimated blood loss during surgery was minimal in all surgeries. Unfractionated heparin was readministered according to the hospital protocol on the night of surgery and titrated to a therapeutic dose. Warfarin was restarted within 2 days postsurgery for all patients. High-risk patients were kept in hospital until postoperative day 6-8 because of concern for delayed bleeding. One patient was noticed to have blood-tinged sputum requiring no intervention; none of the patients developed early or delayed hematemesis. CONCLUSIONS Our data show that bridging therapy with UFH has been successful in chronically anticoagulated patients undergoing tonsillectomy. These patients require multidisciplinary care for the management of their pre- and postoperative course.
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Affiliation(s)
- Inbal Hazkani
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kathleen R Billings
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Evan Edwards
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Eli Stein
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Rukhmi Bhat
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Division of Hematology, Oncology, and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jennifer Lavin
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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4
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Wiegmann AL, Khalid SI, Alba BE, O'Neill ES, Perez-Alvarez I, Maasarani S, Hood KC. “Patients Prescribed Antithrombotic Medication In Elective Implant-Based Breast Reconstruction Are High Risk For Major Thrombotic Complications”. J Plast Reconstr Aesthet Surg 2022; 75:3048-3059. [DOI: 10.1016/j.bjps.2022.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/25/2022] [Accepted: 06/07/2022] [Indexed: 10/18/2022]
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Giannoudi M, Giannoudis PV. Proximal femur fractures in patients taking anti-coagulants: has anything changed? EFORT Open Rev 2022; 7:356-364. [PMID: 35638607 PMCID: PMC9257726 DOI: 10.1530/eor-22-0028] [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] [Indexed: 11/08/2022] Open
Abstract
With an ever-ageing population, the incidence of hip fractures is increasing worldwide. Increasing age is not just associated with increasing fractures but also increasing comorbidities and polypharmacy. Consequently, a large proportion of patients requiring hip fracture surgery (HFS) are also prescribed antiplatelet and anti-coagulant medication. There remains a clinical conundrum with regards to how such medications should affect surgery, namely with regards to anaesthetic options, timing of surgery, stopping and starting the medication as well as the need for reversal agents. Herein, we present the up-to-date evidence on HFS management in patients taking blood-thinning agents and provide a summary of recommendations based on the existing literature.
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Affiliation(s)
- Marilena Giannoudi
- Department of Cardiology, Bradford Teaching Hospitals NHS Trust, Bradford, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Floor D, Clarendon Wing, LGI, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
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Kopanczyk R, Kumar N, Papadimos T. Post-Acute COVID-19 Syndrome for Anesthesiologists: A Narrative Review and a Pragmatic Approach to Clinical Care. J Cardiothorac Vasc Anesth 2021; 36:2727-2737. [PMID: 34688543 PMCID: PMC8487462 DOI: 10.1053/j.jvca.2021.09.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/17/2021] [Accepted: 09/29/2021] [Indexed: 02/07/2023]
Abstract
Post-acute coronavirus disease 2019 (COVID-19) syndrome is a novel, poorly understood clinical entity with life-impacting ramifications. Patients with this syndrome, also known as "COVID-19 long-haulers," often present with nonspecific ailments involving more than one body system. The most common complaints include dyspnea, fatigue, brain fog, and chest pain. There currently is no single agreed-upon definition for post-acute COVID-19 syndrome, but most agree that criterion for this syndrome is the persistence of mental and physical health consequences after initial infection. Given the millions of acute infections in the United States over the course of the pandemic, perioperative providers will encounter these patients in clinical practice in growing numbers. Symptoms of the COVID-19 long-haulers should not be minimized, as these patients are at higher risk for postoperative respiratory complications and perioperative mortality for up to seven weeks after initial illness. Instead, a cautious multidisciplinary preoperative evaluation should be performed. Perioperative care should be viewed through the prism of best practices already in use, such as avoidance of benzodiazepines in patients with cognitive impairment and use of lung-protective ventilation. Recommendations especially relevant to the COVID-19 long-haulers include assessment of critical care myopathies and neuropathies to determine suitable neuromuscular blocking agents and reversal, preoperative workup of insidious cardiac or pulmonary pathologies in previously healthy patients, and, thorough medication review, particularly of anticoagulation regimens and chronic steroid use. In this article, the authors define the syndrome, synthesize the available scientific evidence, and make pragmatic suggestions regarding the perioperative clinical care of COVID-19 long-haulers.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Nicolas Kumar
- The Ohio State University College of Medicine, Columbus, OH
| | - Thomas Papadimos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
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Lock JF, Ungeheuer L, Borst P, Swol J, Löb S, Brede EM, Röder D, Lengenfelder B, Sauer K, Germer CT. Markedly increased risk of postoperative bleeding complications during perioperative bridging anticoagulation in general and visceral surgery. Perioper Med (Lond) 2020; 9:39. [PMID: 33292504 PMCID: PMC7682086 DOI: 10.1186/s13741-020-00170-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasing numbers of patients receiving oral anticoagulants are undergoing elective surgery. Low molecular weight heparin (LMWH) is frequently applied as bridging therapy during perioperative interruption of anticoagulation. The aim of this study was to explore the postoperative bleeding risk of patients receiving surgery under bridging anticoagulation. METHODS We performed a monocentric retrospective two-arm matched cohort study. Patients that received perioperative bridging anticoagulation were compared to a matched control group with identical surgical procedure, age, and sex. Emergency and vascular operations were excluded. The primary endpoint was the incidence of major postoperative bleeding. Secondary endpoints were minor postoperative bleeding, thromboembolic events, length of stay, and in-hospital mortality. Multivariate analysis explored risk factors of major postoperative bleeding. RESULTS A total of 263 patients in each study arm were analyzed. The patient cohort included the entire field of general and visceral surgery including a large proportion of major oncological resections. Bridging anticoagulation increased the postoperative incidence of major bleeding events (8% vs. 1%; p < 0.001) as well as minor bleeding events (14% vs. 5%; p < 0.001). Thromboembolic events were equally rare in both groups (1% vs. 2%; p = 0.45). No effect on mortality was observed (1.5% vs. 1.9%). Independent risk factors of major postoperative bleeding were full-therapeutic dose of LMWH, renal insufficiency, and the procedure-specific bleeding risk. CONCLUSION Perioperative bridging anticoagulation, especially full-therapeutic dose LMWH, markedly increases the risk of postoperative bleeding complications in general and visceral surgery. Surgeons should carefully consider the practice of routine bridging.
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Affiliation(s)
- J F Lock
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Zentrum Operative Medizin, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
| | - L Ungeheuer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Zentrum Operative Medizin, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - P Borst
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Zentrum Operative Medizin, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - J Swol
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Zentrum Operative Medizin, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - S Löb
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Zentrum Operative Medizin, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - E M Brede
- Department of Anesthesia and Critical Care, University Hospital of Würzburg, Würzburg, Germany
| | - D Röder
- Department of Anesthesia and Critical Care, University Hospital of Würzburg, Würzburg, Germany
| | - B Lengenfelder
- Department of Medicine/Cardiology, University Hospital of Würzburg, Würzburg, Germany
| | - K Sauer
- Central Laboratory, University Hospital of Würzburg, Würzburg, Germany
| | - C-T Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Zentrum Operative Medizin, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
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Abstract
Thirty per cent of patients presenting with proximal femoral fractures are receiving anticoagulant treatment for various other medical reasons. This pharmacological effect may necessitate reversal prior to surgical intervention to avoid interference with anaesthesia or excessive peri/post-operative bleeding. Consequently, delay to surgery usually occurs. Platelet inhibitors (aspirin, clopidogrel) either alone or combined do not need to be discontinued to allow acute hip surgery. Platelet transfusions can be useful but are rarely needed. Vitamin K antagonists (VKA, e.g. warfarin) should be reversed in a timely fashion and according to established readily accessible departmental protocols. Intravenous vitamin K on admission facilitates reliable reversal, and platelet complex concentrate (PCC) should be reserved for extreme scenarios. Direct oral anticoagulants (DOAC) must be discontinued prior to hip fracture surgery but the length of time depends on renal function ranging traditionally from two to four days. Recent evidence suggests that early surgery (within 48 hours) can be safe. No bridging therapy is generally recommended. There is an urgent need for development of new commonly available antidotes for every DOAC as well as high-level evidence exploring DOAC effects in the acute hip fracture surgical setting.
Cite this article: EFORT Open Rev 2020;5:699-706. DOI: 10.1302/2058-5241.5.190071
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Affiliation(s)
- Ioannis V Papachristos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK.,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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10
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Abstract
PURPOSE OF REVIEW The management of patients with mechanical heart valves who require surgery or invasive procedures is a common clinical scenario in contemporary practice. The risk of thromboembolism versus the risk of bleeding is the foundation of optimal patient care. RECENT FINDINGS Randomized, controlled trials are not available; yet, there is a wealth of experience to guide best practice. Current guidelines represent a compilation of data from trials of atrial fibrillation and expert opinion. Results from the PERI-OP trial of patients with either a mechanical heart valve, atrial fibrillation, or atrial flutter requiring interruption of oral anticoagulant therapy for surgery will inform clinical practice. Patient-specific factors and valve-specific factors are paramount when deciding whether a period of anticoagulant therapy interruption is safe. Similarly, the safety and efficacy of bridging anticoagulant therapy and the optimal time after surgery for restarting oral anticoagulants is vital to optimal patient care.
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Affiliation(s)
- Mahboob Ali
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0542, CVC, Room 4936, Cincinnati, OH, 45267-0542, USA
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0542, CVC, Room 4936, Cincinnati, OH, 45267-0542, USA.
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Ibdah RK, Rawashdeh SI, Harahsheh E, Almegdadi A, Al. Ksassbeh A, Alrabadi N. The Knowledge and Perception of Antiplatelet and Anticoagulant agents among Dentists in Northern Jordan. J Int Soc Prev Community Dent 2020; 10:597-604. [PMID: 33282769 PMCID: PMC7685271 DOI: 10.4103/jispcd.jispcd_70_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/15/2020] [Accepted: 07/02/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The aim of this study was to describe the attitude and perception toward antiplatelet/anticoagulant agents in patients with cardiovascular diseases among dentists in the northern district of Jordan and to compare the current practice of Jordanian dentists and the recently published guidelines regarding the management of patients taking antiplatelet/anticoagulant drugs before dental procedures. MATERIALS AND METHODS This is a cross-sectional study conducted on dentists and dental interns working at the dental clinics in northern Jordan, including dental clinics at Jordan University of Science and Technology (JUST) and the private sector. The total sample size comprised of 128 subjects (78 dentists from JUST and 50 private practitioners). The participants were interviewed using a preformed questionnaire to assess their knowledge and perceptions regarding the antiplatelets and the anticoagulant agents. RESULTS Approximately 61.5% of participants from JUST university and 20.0% of those in the private sector were aware of the use of clopidogrel (P < 0.0001). Although the overall awareness regarding other antiplatelets such as prasugrel was very low (8.6%), dentists from JUST (12.8%) showed a significantly higher level of awareness compared to the private practitioners (2.0%) (P = 0.049). More than 70% of the participants from JUST and only 46.0% of the private practitioners were aware of the consequences of interrupting treatment with clopidogrel in patients with coronary stents (P = 0.002). Almost both the participants from JUST (25.78%) and the private sector (24.22%) are consulting the cardiologists with similar frequencies before interrupting the treatment with the antiplatelet/anticoagulant agents. Participants who have clinical PhD qualifications are more aware of the recent clinical guidelines and the newest agents compared to others. CONCLUSIONS The awareness regarding the newest antiplatelet/anticoagulant agents is poor among the dentists in northern Jordan. However, the majority (62.3%) of them realize the consequences of interrupting such treatments in patients with coronary stents. Unfortunately, only a quarter of the dentists are consulting the cardiologists before interrupting the treatment with the antiplatelet agents. Proper education, courses, and workshops should be performed to the dentists to improve their knowledge about this critical issue.
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Affiliation(s)
- Rasheed K Ibdah
- Division of Cardiology, Department of Internal Medicine, Jordan University for Science and Technology, Irbid, Jordan
| | - Sukaina I Rawashdeh
- Division of Cardiology, Department of Internal Medicine, Jordan University for Science and Technology, Irbid, Jordan
| | - Ehab Harahsheh
- Department of Neurology, Mayo Clinic College of Medicine, Arizona, USA
| | - Abdallah Almegdadi
- Division of Cardiology, Department of Internal Medicine, Jordan University for Science and Technology, Irbid, Jordan
| | - Abdullah Al. Ksassbeh
- Division of Cardiology, Department of Internal Medicine, Jordan University for Science and Technology, Irbid, Jordan
| | - Nasr Alrabadi
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Andonegui J, Capdevila F, Zubicoa A, Ibáñez B. Randomised controlled trial on vitreoretinal surgery with and without oral anticoagulants: surgical complications, visual results and perioperative thromboembolic events. Trials 2019; 20:677. [PMID: 31801597 PMCID: PMC6894279 DOI: 10.1186/s13063-019-3805-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vitreoretinal surgery in anticoagulated patients is a challenging situation for vitreoretinal surgeons, who have to choose between being faced with the systemic thromboembolic risks that the interruption of anticoagulation involves, or the intra- and postoperative haemorrhagic risks associated with maintenance of this therapy. So far, no trial has compared, in a prospective and randomized manner, perioperative complications and the visual results associated with continuation or interruption of oral anticoagulant therapy before pars plana vitrectomy (PPV) under retrobulbar anaesthesia. The main objective of this trial is to compare haemostasis-related perioperative complications of PPV in patients maintaining anticoagulant therapy before surgery compared to patients with an interruption in this therapy before surgery. METHODS Ninety-six patients will be randomly assigned to either the control group, in whom oral anticoagulant therapy will be interrupted and substituted with subcutaneous heparin according to local clinical practice, or the intervention group in whom oral anticoagulant therapy will not be interrupted before surgery. Patients will be stratified according to the oral anticoagulant they were taking (direct or indirect anticoagulation). They will be followed up for 12 weeks, and the primary outcome, and haemorrhagic complications until 15 days after surgery, will be evaluated. DISCUSSION This trial will provide novel information on the possibility of continuing anticoagulant therapy during PPV. The benefits expected from the change in the current surgical management paradigm for anticoagulated patients would be a decreased risk in the incidence of perioperative thromboembolic events and the possibility of performing surgery without delay and without the need for patients to change their usual anticoagulation protocol to the more complex and less safe substitutive therapy. TRIAL REGISTRATION Clinical Trials Register EudraCT, 2018-000753-45. Registered on 11 November 2018.
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Affiliation(s)
- Jose Andonegui
- Department of Ophthalmology, Complejo Hospitalario de Navarra, 31007, Pamplona, Spain. .,Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.
| | - Ferran Capdevila
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.,Navarrabiomed, Complejo Hospitalario de Navarra, Universidad Pública de Navarra, Pamplona, Spain
| | - Alicia Zubicoa
- Department of Ophthalmology, Complejo Hospitalario de Navarra, 31007, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Berta Ibáñez
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.,Navarrabiomed, Complejo Hospitalario de Navarra, Universidad Pública de Navarra, Pamplona, Spain.,Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), Pamplona, Spain
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13
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How to bridge? Management of anticoagulation in patients with mechanical heart valves undergoing noncardiac surgical procedures. J Thorac Cardiovasc Surg 2018; 158:200-203. [PMID: 30107917 DOI: 10.1016/j.jtcvs.2018.06.089] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/16/2018] [Accepted: 06/25/2018] [Indexed: 11/23/2022]
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14
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Chossat A, Marco O, Chaouat M, Mimoun M, Boccara D. [Complications with surgical treatment of basal cell carcinomas in individuals over 75 years of age: A retrospective study of prognostic factors in 158 cases]. ANN CHIR PLAST ESTH 2018; 63:299-306. [PMID: 29887383 DOI: 10.1016/j.anplas.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/13/2018] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Basal cell carcinoma (BCC) is a pathology that evolves locally and it is common in elderly subjects whose frailty could restrict the indications for the reference treatment, which is based on surgery. The aim of this study was to investigate the morbidity and the mortality associated with surgical treatment of BCC in patients over 75 years of age, so as to identify possible prognostic factors for postoperative complications. MATERIALS AND METHODS This was a retrospective study carried out with patients over 75 years of age who were treated surgically for one or several BCC between 2010 and 2015 in the reconstructive and cosmetic plastic surgery unit of the Saint-Louis Hospital in Paris (France). We collated the demographic characteristics, the characteristics of the treatment, as well as the rate of major postoperative complications. We performed a univariate and then a multivariate analysis of the various risk factors that were identified. RESULTS A total of 158 patients were analyzed and they exhibited a rate of major complications of 12%. The statistical analysis identified five significant risk factors: being over 85 years of age (P=0.006), long-term use of anticoagulant treatment (P=0.02), the presence of at least one comorbidity (P=0.018), a conventional hospitalization (P=0.002), and the use of general anesthesia (P=1.2e-10). CONCLUSION Five risk factors for major postoperative complications with the surgical treatment of BCC in patients over 75 years of age were identified. These factors may provide direction to medico-surgical teams in regard to the optimal treatment of BCC in elderly patients.
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Affiliation(s)
- A Chossat
- Service de chirurgie plastique réparatrice et esthétique, centre hospitalier René-Dubos, 6, avenue de l'Île-de-France, 95300 Pontoise, France.
| | - O Marco
- Service de chirurgie plastique réparatrice et esthétique, CHU Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - M Chaouat
- Service de chirurgie plastique réparatrice et esthétique, CHU Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - M Mimoun
- Service de chirurgie plastique réparatrice et esthétique, CHU Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - D Boccara
- Service de chirurgie plastique réparatrice et esthétique, CHU Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
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15
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Antiplatelet and anticoagulant agents in vitreoretinal surgery: a prospective multicenter study involving 804 patients. Graefes Arch Clin Exp Ophthalmol 2018; 256:461-467. [DOI: 10.1007/s00417-017-3897-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/08/2017] [Accepted: 12/29/2017] [Indexed: 01/07/2023] Open
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16
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Abuqayyas S, Raju S, Bartholomew JR, Abu Hweij R, Mehta AC. Management of antithrombotic agents in patients undergoing flexible bronchoscopy. Eur Respir Rev 2017; 26:26/145/170001. [PMID: 28724561 DOI: 10.1183/16000617.0001-2017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 04/09/2017] [Indexed: 12/16/2022] Open
Abstract
Bleeding is one of the most feared complications of flexible bronchoscopy. Although infrequent, it can be catastrophic and result in fatal outcomes. Compared to other endoscopic procedures, the risk of morbidity and mortality from the bleeding is increased, as even a small amount of blood can fill the tracheobronchial tree and lead to respiratory failure. Patients using antithrombotic agents (ATAs) have higher bleeding risk. A thorough understanding of the different ATAs is critical to manage patients during the peri-procedural period. A decision to stop an ATA before bronchoscopy should take into account a variety of factors, including indication for its use and the type of procedure. This article serves as a detailed review on the different ATAs, their pharmacokinetics and the pre- and post-bronchoscopy management of patients receiving these medications.
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Affiliation(s)
- Sami Abuqayyas
- Internal Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.,Both authors contributed equally
| | - Shine Raju
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Both authors contributed equally
| | | | - Roulan Abu Hweij
- Internal Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Atul C Mehta
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Lum DJ, Ross PA, Bishop MA, Caetano ML, Malpani R, Streiff MB. Evaluation of a Standardized Perioperative Management Protocol in the Adult Hematology Anticoagulation Management Service. Ann Pharmacother 2017; 51:1077-1083. [PMID: 28677422 DOI: 10.1177/1060028017719505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In North America, 250,000 patients on vitamin K antagonists require surgical procedures each year. Temporary interruption of oral anticoagulation and perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin are recommended by the American College of Chest Physicians 2012 for select patients. OBJECTIVES The study objectives are to evaluate adherence and nonadherence to the Johns Hopkins clinic guidelines for perioperative management of anticoagulation and identify bleeding or thromboembolic events during perioperative management of anticoagulation. METHODS This is a retrospective study of patients who required perioperative management of anticoagulation for an invasive procedure from May 2009 to March 2014. Individualized perioperative anticoagulation management plans were prospectively developed for each patient according to the standardized Johns Hopkins perioperative bridging recommendations and documented in the medical record. Adherence to these standardized Johns Hopkins clinic guidelines, the incidence of thromboembolic events, and bleeding and adverse events during perioperative management were retrieved from the medical record. RESULTS In 294 perioperative management cases, there was 1 (0.3%) thromboembolism, 3 (1%) major bleeds, and 21 (7%) minor bleeds. One patient experienced facial swelling after starting enoxaparin. There was no difference in thromboembolic (0 vs 1, P = 1.00), major (1 vs 2, P = 1.00), or minor bleeding (14 vs 7, P = 1.00) events in patients managed by providers who were adherent to guidelines when compared with providers who were nonadherent. CONCLUSION Our study shows that using a standardized guideline for perioperative management of anticoagulation to inform but not to dictate clinical practice leads to low rates of both thromboembolism and bleeding.
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Affiliation(s)
- Diane J Lum
- 1 The Johns Hopkins Hospital, Baltimore, MD, USA.,2 Stony Brook University Hospital, Stony Brook, NY, USA
| | | | | | | | | | - Michael B Streiff
- 1 The Johns Hopkins Hospital, Baltimore, MD, USA.,5 The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Perioperative care of the patients with neurological diseases can be challenging. Most important consideration is the management and understanding of pathophysiology of these disorders and evaluation of new neurological changes that occur perioperatively. Perioperative generally refers to 3 phases of surgery: preoperative, intraoperative, and postoperative. We have tried to address few commonly encountered neurological conditions in clinical practice, such as delirium, stroke, epilepsy, myasthenia gravis, and Parkinson disease. In this article, we emphasize on early diagnosis and management strategies of neurological disorders in the perioperative period to minimize morbidity and mortality of patients.
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Affiliation(s)
- Manjeet Singh Dhallu
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmed Baiomi
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhavi Biyyam
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sridhar Chilimuri
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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19
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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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20
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Results of surgery in general surgical patients receiving warfarin: retrospective analysis of 61 patients. Int Surg 2016; 100:225-32. [PMID: 25692422 DOI: 10.9738/intsurg-d-14-00139.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The aim of this study is to investigate postoperative complications, mortality rates, and to determine the factors affecting mortality on the patients receiving warfarin therapy preoperatively, as well as comparing the results obtained from emergency and elective surgeries. Surgical outcomes of 61 patients on long-term oral anticoagulation with warfarin who underwent surgery in our center were retrospectively reviewed over an 8-year period. Thirty-three (54.1%) patients were female, with a mean age of 53 years. Mitral valve replacement (62.3%) was the most frequent indication for chronic anticoagulation therapy. Twelve out of 61 (19.2%) patients underwent emergency surgery; 59 (96.7%) operations were classified as major surgery. We did not observe any thromboembolic events on patients receiving our bridging therapy protocol. Cardiopulmonary dysfunction (CPD; 19.7%) and hemorrhage (16.4%) were the most encountered postoperative complications. Presence of CPD, bleeding, endocarditis, and mortality were statistically significant for emergency surgeries when compared with the results obtained from elective surgeries. There were 5 (8.2%) deaths observed during follow-up. It was found that advanced age, prolonged duration of operations, and presence of CPD had a statistically significant effect on mortality (P < 0.05). The patients receiving oral anticoagulant had high postoperative complication and mortality rates. This case was more evident in emergency surgeries. It is recommendable that as mortality is more apparent in the patients who undergo emergency surgeries-being older, having long duration of operations as well as CPD. Therefore during the postoperative follow-up process, the patients should be closely monitored.
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Abstract
Objectives: The objectives of this study were to review perioperative bridging strategies for anticoagulated patients and to describe a novel bridging strategy for tonsillectomy in an anticoagulated patient that addresses both primary and secondary hemorrhage risks. Methods: A literature review and a case report are presented. PubMed was reviewed for evidence-based recommendations on perioperative management of anticoagulated patients. A case report is detailed of a 28-year-old woman with antiphospholipid syndrome on warfarin for high risk of venous thrombosis who underwent tonsillectomy. A perioperative bridging strategy incorporating outpatient low–molecular weight heparin and inpatient unfractionated heparin was implemented to minimize risks of thrombosis and primary and secondary posttonsillectomy hemorrhage. Results: Limited evidence supports a consensus on the best perioperative management of anticoagulated patients. Tonsillectomy in an anticoagulated patient has not been described previously. The patient in this case underwent successful tonsillectomy with no thrombosis or bleeding after 1 month of follow-up. Conclusions: Tonsillectomy can be done relatively safely in an anticoagulated patient at high risk for thrombosis. The perioperative bridging strategy should account for its unique risk of primary and secondary postoperative hemorrhage. A proposed algorithm for managing these competing risks is presented.
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Affiliation(s)
- Stephanie M Cole
- Department of Otolaryngology, Naval Medical Center San Diego, CA 92134, USA
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22
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Sweis R, Biller J. Practical Guide to Direct New Oral Anticoagulant Use for Secondary Stroke Prevention in Atrial Fibrillation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:24. [PMID: 26909818 DOI: 10.1007/s11936-016-0446-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OPINION STATEMENT Anticoagulation remains the optimal treatment choice for secondary stroke prevention of AF. The vitamin K antagonists (VKAs) have been the choice of treatment for the last 60 years, but the new oral anticoagulants are now a safe option for treatment of non-valvular AF (NVAF) in the right patient population, taking into account age, renal function, bleeding risk, cardiovascular comorbidities, cost, and drug interactions.
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Affiliation(s)
- Rochelle Sweis
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA.
| | - José Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA.
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23
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Anticoagulation for Hypercoagulable Patients Associated with Complications after Large Cranioplasty Reconstruction. Plast Reconstr Surg 2016; 137:595-607. [DOI: 10.1097/01.prs.0000475773.99148.ba] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rechenmacher SJ, Fang JC. Bridging Anticoagulation: Primum Non Nocere. J Am Coll Cardiol 2016; 66:1392-403. [PMID: 26383727 DOI: 10.1016/j.jacc.2015.08.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 08/03/2015] [Indexed: 12/17/2022]
Abstract
Chronic oral anticoagulation frequently requires interruption for various reasons and durations. Whether or not to bridge with heparin or other anticoagulants is a common clinical dilemma. The evidence to inform decision making is limited, making current guidelines equivocal and imprecise. Moreover, indications for anticoagulation interruption may be unclear. New observational studies and a recent large randomized trial have noted significant perioperative or periprocedural bleeding rates without reduction in thromboembolism when bridging is employed. Such bleeding may also increase morbidity and mortality. In light of these findings, physician preferences for routine bridging anticoagulation during chronic anticoagulation interruptions may be too aggressive. More randomized trials, such as PERIOP2 (A Double Blind Randomized Control Trial of Post-Operative Low Molecular Weight Heparin Bridging Therapy Versus Placebo Bridging Therapy for Patients Who Are at High Risk for Arterial Thromboembolism), will help guide periprocedural management of anticoagulation for indications such as venous thromboembolism and mechanical heart valves. In the meantime, physicians should carefully consider both the need for oral anticoagulation interruption and the practice of routine bridging when anticoagulation interruption is indicated.
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Affiliation(s)
- Stephen J Rechenmacher
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah.
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
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25
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Factors associated with postoperative complications in elderly patients with skin cancer: A retrospective study of 241 patients. J Geriatr Oncol 2016; 7:10-4. [DOI: 10.1016/j.jgo.2015.11.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 10/03/2015] [Accepted: 11/30/2015] [Indexed: 11/22/2022]
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26
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Shah AH, Khalil HS, Alshahrani FA, Khan SQ, AlQthani NR, Bukhari IA, Kola MZ. Knowledge of medical and dental practitioners towards dental management of patients on anticoagulant and/or anti-platelet therapy. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.sjdr.2014.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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27
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Continuation of anticoagulant and antiplatelet therapy during phacoemulsification cataract surgery. Curr Opin Ophthalmol 2015; 26:28-33. [PMID: 25390860 DOI: 10.1097/icu.0000000000000117] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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28
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Management of non-vitamin K antagonist oral anticoagulants in the perioperative setting. BIOMED RESEARCH INTERNATIONAL 2014; 2014:385014. [PMID: 25276784 PMCID: PMC4168027 DOI: 10.1155/2014/385014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 08/05/2014] [Indexed: 12/29/2022]
Abstract
The field of oral anticoagulation has evolved with the arrival of non-vitamin K antagonist oral anticoagulants (NOACs) including an anti-IIa agent (dabigatran etexilate) and anti-Xa agents (rivaroxaban and apixaban). The main specificities of these drugs are predictable pharmacokinetics and pharmacodynamics but special attention should be paid in the elderly, in case of renal dysfunction and in case of emergency. In addition, their perioperative management is challenging, especially with the absence of specific antidotes. Effectively, periods of interruption before surgery or invasive procedures depend on half-life and keeping a permanent balance between bleeding and thromboembolic risks. In addition, few data regarding the link between plasma concentrations and their effects are provided. Routine laboratory tests are altered by NOACs and quantitative measurements are not widely performed. This paper provides a review on the management of NOACs in the perioperative setting, including the estimation of the bleeding and thrombotic risk, the periods of interruption, the indication of heparin bridging, the usefulness of laboratory tests before surgery or invasive procedure, and the time of resuming. Most data are based on expert's opinions.
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Probasco J, Sahin B, Tran T, Chung TH, Rosenthal LS, Mari Z, Levy M. The preoperative neurological evaluation. Neurohospitalist 2014; 3:209-20. [PMID: 24198903 DOI: 10.1177/1941874413476042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Neurological diseases are prevalent in the general population, and the neurohospitalist has an important role to play in the preoperative planning for patients with and at risk for developing neurological disease. The neurohospitalist can provide patients and their families as well as anesthesiologists, surgeons, hospitalists, and other providers guidance in particular to the patient's neurological disease and those he or she is at risk for. Here we present considerations and guidance for the neurohospitalist providing preoperative consultation for the neurological patient with or at risk of disturbances of consciousness, cerebrovascular and carotid disease, epilepsy, neuromuscular disease, and Parkinson disease.
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Affiliation(s)
- John Probasco
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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31
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Paradigm change in the treatment of non-melanoma skin cancer of the auricle: reconstruction with full thickness skin grafting instead of wedge excision. Eur Arch Otorhinolaryngol 2014; 272:1743-8. [PMID: 24871861 DOI: 10.1007/s00405-014-3092-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Accepted: 05/06/2014] [Indexed: 10/25/2022]
Abstract
Non-melanoma skin cancer (NMSC) has become an epidemic disease and is predominantly located in the head and neck area. While historically auricular NMSCs are treated by means of a wedge excision, we describe a more elegant technique with excellent esthetical results. We conducted a retrospective cohort study of 43 consecutive patients with NMSC of the auricle who underwent reconstruction with a full thickness skin graft (FTSG). All grafts survived. Two patients (5%) showed crust formation, but fully recovered. One patient had an irradical resection for which he required a limited re-excision. All patients showed excellent esthetical results. When treating NMSC of the auricle, reconstruction with a FTSG demonstrates several important advantages. It is a relatively simple but oncological safe technique; it leads to excellent esthetical and functional outcomes, and shows high patient and surgeon satisfaction.
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Bleeding complications in patients with coronary stents during non-cardiac surgery. Thromb Res 2014; 134:268-72. [PMID: 24913999 DOI: 10.1016/j.thromres.2014.05.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 05/12/2014] [Accepted: 05/12/2014] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Patients with coronary stents often undergo non-cardiac invasive procedures. These are often associated with thrombotic and/or hemorrhagic complications. The type of procedure, perioperative antiplatelet therapy, and other patient-related factors influence the risk of postoperative haemorrhage. Our objective was to analyze the postoperative risk factors for hemorrhagic complications and to determine the impact of antiplatelet and anticoagulant therapy strategies on postoperative bleeding risk in patients with coronary stents undergoing non-cardiac surgery. PATIENTS AND METHODS Prospective, multicentre observational cohort study of 1134 consecutive patients with coronary stents undergoing non-cardiac surgery between April 2007 and April 2009. The primary outcome measure was the occurrence of an hemorrhagic complication during the first 30days following the surgery or intervention. RESULTS Among the 1134 patients evaluated, 108 (9.5%) experienced a postoperative hemorrhagic complication (with a median time to occurrence of 5.3days). These complications were considered major, involved the operative site, and required reoperation in 92 (85.2%), 92 (85.2%), and 20 (18.5%) of patients, respectively. Mortality in patients with a haemorrhagic complication was 12% (n=13). Independent postoperative factors associated with haemorrhagic complications were identified as a high and intermediate bleeding risk procedure and the use and dose of anticoagulants. When interrupted before the procedure, resumption of antiplatelet treatment was delayed in patients developing early postoperative hemorrhagic complications. CONCLUSION Patients with coronary stents who undergo surgery are at high risk for hemorrhagic complications.
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Bonhomme F, Fontana P, Reny JL. How to manage prasugrel and ticagrelor in daily practice. Eur J Intern Med 2014; 25:213-20. [PMID: 24529662 DOI: 10.1016/j.ejim.2014.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 12/13/2022]
Abstract
Prasugrel and ticagrelor are next-generation antiplatelet agents that provide a rapider and more potent inhibition of platelet P2Y12 receptor than clopidogrel. In combination with aspirin, these new P2Y12 inhibitors are now the first line treatments for patients with acute coronary syndrome. However, these potent antiplatelet agents introduce a new paradigm in the daily management of antithrombotic drugs, particularly when an invasive procedure is planned. The pharmacology of these antiplatelet agents, and the results of the main clinical trials, are reviewed with a special focus on good prescription practices (indications, contra-indications, drug interactions), and on peri-operative management. Strategies are proposed for safely reducing the bleeding risk in elderly patients, in patients requiring concomitant oral anticoagulant therapy, or in patients with an increased haemorrhagic risk.
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Affiliation(s)
- Fanny Bonhomme
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of Anaesthesiology, Geneva University Hospitals, Geneva, Switzerland.
| | - Pierre Fontana
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of Angiology and Haemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Luc Reny
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of General Internal Medicine and Rehabilitation, Trois-Chêne, Geneva University Hospitals, Geneva, Switzerland
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Joo J. Periprocedural antithrombotic management. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2014. [DOI: 10.5124/jkma.2014.57.5.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jin Joo
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Abstract
With populations ageing and active treatment of urinary stones increasingly in demand, more patients with stones are presenting with an underlying bleeding disorder or need for regular thromboprophylaxis, by means of antiplatelet and other medication. A practical guide to thromboprophylaxis in the treatment of urinary tract lithiasis has not yet been established. Patients can be stratified according to levels of risk of arterial and venous thromboembolism, which influence the requirements for antiplatelet and anticoagulant medications, respectively. Patients should also be stratified according to their risk of bleeding. Consideration of the combined risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. The choice of shockwave lithotripsy, percutaneous nephrolithotomy or ureteroscopy with laser lithotripsy for treatment of lithiasis should be determined with regard to these risks. Although ureteroscopy is the preferred method in high-risk patients, shockwave lithotripsy and percutaneous nephrolithotomy can be chosen when indicated, if appropriate guidelines are strictly followed.
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Ahmed I, Khan MA, Nayak V, Mohsen A. An evidence-based warfarin management protocol reduces surgical delay in hip fracture patients. J Orthop Traumatol 2013; 15:21-7. [PMID: 24276249 PMCID: PMC3948519 DOI: 10.1007/s10195-013-0274-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 09/25/2013] [Indexed: 11/05/2022] Open
Abstract
Background Up to 4 % of patients presenting with a hip fracture may be on warfarin at admission. There is little consensus on the timing, dosage or route of vitamin K administration. We aimed to evaluate the impact of a locally developed, evidence-based protocol for perioperative warfarin management on the admission-to-operation time (AOT) in hip fracture patients. Materials and methods Clinical and demographic data were collected prospectively for hip fracture patients who were on warfarin at the time of admission (post-protocol group) and compared to a historical control group of patients who were on warfarin before implementation of the protocol (pre-protocol group). Univariate analysis was undertaken to identify any significant differences between the two groups. Results Twenty-seven patients in the pre-protocol group (27/616, 4.4 %) and 40 patients in the post-protocol group (4.7 %, 40/855) were on warfarin at admission. There was a significant reduction in the median AOT from 73 h (IQR 46–105) to 37.7 h (IQR 28–45) after implementation of the warfarin protocol (p < 0.001). The proportion of patients operated on within 48 h of admission increased from 30 % (8/27) in the pre-protocol group to 80 % (32/40) in the post-protocol group (p < 0.001). No significant differences in hospital length of stay (p = 0.77) or the postoperative warfarin recommencement time (p = 0.90) were noted between the two groups. Conclusion Implementation of a perioperative warfarin management protocol can expedite surgery in hip fracture patients, but did not reduce hospital stay in our cohort, possibly because of a delay in recommencing warfarin in these patients postoperatively. Level of evidence Level III.
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Affiliation(s)
- I Ahmed
- Department of Anaesthesia and Critical Care, Hull Royal Infirmary, Anlaby Road, Kingston upon Hull, HU3 2JZ, UK,
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Young EY, Ahmadinia K, Bajwa N, Ahn NU. Does chronic warfarin cause increased blood loss and transfusion during lumbar spinal surgery? Spine J 2013; 13:1253-8. [PMID: 23871508 DOI: 10.1016/j.spinee.2013.05.052] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 03/07/2013] [Accepted: 05/28/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The use of oral anticoagulation therapy such as warfarin is projected to increase significantly as the population ages and the prevalence of cardiovascular disease increases. Current recommendations state that warfarin be discontinued before surgery and the international normalized ratio (INR) normalized. PURPOSE To determine if stopping warfarin 7 days before surgery and correcting INR had any effect on intraoperative blood loss or the requirements for blood product transfusion. STUDY DESIGN/SETTING This was a retrospective cohort study in a high-volume tertiary care center. PATIENT SAMPLE Sample comprised 263 consecutive patients who underwent elective lumbar spinal surgery. OUTCOME MEASURE The outcome measures were intraoperative blood loss, intraoperative blood transfusion, postoperative blood transfusion, and the number of blood products transfused. METHODS The records of patients undergoing elective spinal surgery were analyzed for patient demographic data, comorbidities, coagulation panel laboratory findings, operative characteristics, blood loss, and blood transfusion requirements. These included patients undergoing full laminectomies with or without posterolateral fusion and instrumentation. Patients on warfarin were analyzed for the mean dosage of warfarin and underlying pathology that required anticoagulation. All patients on warfarin had their anticoagulation therapy stopped 7 days before surgery and their INR checked preoperatively to confirm normalization. Both univariate and multiple linear regression analyses were performed. RESULTS The patients on warfarin had a mean intraoperative blood loss of 839 mL compared with 441 mL for patients not on warfarin (p<.01). Multiple regression analysis determined that warfarin and number of spinal levels decompressed/fused/instrumented were predictors for increased blood loss (R(2)=0.37). Patients on warfarin also had increased postoperative blood transfusions (23.1% compared with 7.4%, p=.04). There was no significant difference between groups in terms of intraoperative blood transfusion or number of units transfused. CONCLUSIONS Patients on chronic anticoagulation therapy with warfarin who have their therapy stopped 7 days before surgery and have their INR normalized still demonstrated increased intraoperative blood loss and requirement for postoperative transfusion. Surgeons should be aware of the increased propensity of these patients to bleed despite adherence to protocols and should attempt to mitigate this risk.
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Affiliation(s)
- Ernest Y Young
- Department of Orthopaedics, Case Western Reserve University School of Medicine and University Hospitals Case Medical Center, 1585 Rydalmount Rd, Cleveland Heights, OH 44118, USA.
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Faggioli G, Pini R, Rapezzi C, Mauro R, Freyrie A, Gargiulo M, Bacchi Reggiani L, Stella A. Carotid revascularization in patients with ongoing oral anticoagulant therapy: the advantages of stent placement. J Vasc Interv Radiol 2013; 24:370-7. [PMID: 23433413 DOI: 10.1016/j.jvir.2012.11.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 11/29/2012] [Accepted: 11/30/2012] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To assess the influence of oral anticoagulant therapy conversion to heparin (OAT-CH) on carotid endarterectomy (CEA) outcomes and the influence of unmodified oral anticoagulant therapy (OAT) on carotid artery stenting (CAS) and to compare the outcomes of CEA in OAT-CH with CAS in ongoing OAT. MATERIALS AND METHODS The 30-day results from all patients who underwent CEA and CAS in a 6-year period were analyzed for stroke, death, myocardial infarction (MI), and hematoma of the access site requiring surgical evacuation. We evaluated the influence of OAT-CH in CEA and the influence of OAT in CAS and compared CEA and CAS outcomes in patients receiving OAT-CH and OAT. RESULTS Among 1,222 carotid revascularizations, there were 711 CEAs (58.1%) and 511 CAS procedures (41.9%). In the CEA group, 31 (4.4%) patients were treated with OAT-CH, and these patients had a significantly higher complication rate compared with patients not receiving OAT, including death (1 [3.2%] vs 4 [0.6%]; P = .04), stroke (4 [12.9%] vs 10 [1.4%]; P = .001), and hematoma (3 [9.6%] vs 11 [1.6%]; P = .02). In CAS, the results were similar in patients receiving OAT (30 [5.8%]) and patients not receiving OAT. Patients receiving OAT who underwent CAS had better outcomes than patients receiving OAT-CH who underwent CEA, including stroke, death, MI, and hematoma combined (0 [0.0%] vs 7 [22.5%]; P =.01). CONCLUSIONS OAT management significantly influences the results of carotid revascularization. Because CAS with unmodified OAT had a significantly better outcome than CEA with OAT-CH, carotid revascularization strategies should favor CAS rather than CEA in this setting.
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Affiliation(s)
- Gianluca Faggioli
- Department of Vascular Surgery, University of Bologna, Via Massarenti 11, Bologna 40138, Italy
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Preoperative identification of patients with increased risk for perioperative bleeding. Curr Opin Anaesthesiol 2013; 26:82-90. [DOI: 10.1097/aco.0b013e32835b9a23] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Park KK, Chung MS, Chung SY, Kim JH, Chung BH. Effects of post biopsy digital rectal compression on improving prostate cancer staging using magnetic resonance imaging in localized prostate cancer. Yonsei Med J 2013; 54:81-6. [PMID: 23225802 PMCID: PMC3521275 DOI: 10.3349/ymj.2013.54.1.81] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To evaluate the effectiveness of digital rectal-compression immediately after transrectal prostate biopsy (P-bx) for improving the accuracy of prostate cancer (PCa) staging. MATERIALS AND METHODS Between July 2008 and June 2010, 94 consecutive patients who had a radical prostatectomy were included in our retrospective analysis. The exclusion criteria included a history of previous P-bx and surgery, a biopsy performed in another hospital, a number of biopsy cores different from 12, or a condition interfering with bleeding assessment. The subjects were divided into two groups, compression and non-compression. All enrolled patients took magnetic resonance imaging (MRI) for PCa staging. RESULTS The compression and non-compression groups were comparable with respect to several baseline characteristics. However, the total hemorrhage score of intraprostatic bleeding was significantly different between the groups, even with adjustment for the time from biopsy to MRI (compression:15.4 ± 2.32, non-compression: 24.9 ± 2.43, p<0.001). The intra-prostatic cancer location matching rate was higher in the compression group (78.0%) than in the non-compression group (70.2%) (p = 0.011). Overall accuracy of staging in compression and non-compression groups was 84.7% and 77.3%, respectively. CONCLUSION Our results demonstrate that digital rectal compression performed immediately after prostate biopsy to reduce intraprostatic hemorrhage improves the accuracy for detection of PCa using MRI.
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Affiliation(s)
- Kyung Kgi Park
- Department of Urology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Mun Su Chung
- Department of Urology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea
| | - Soo Yoon Chung
- Department of Radiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Joo Hee Kim
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Ha Chung
- Department of Urology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Philip I, Leblanc I, Berroëta C, Mouren S, Chterev V, Bourel P. Fibrillation atriale en anesthésie–réanimation : de la cardiologie médicale à la période périopératoire. ACTA ACUST UNITED AC 2012; 31:897-910. [DOI: 10.1016/j.annfar.2012.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 08/20/2012] [Indexed: 01/11/2023]
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Kose R, Sogut O, Demir T, Koruk I. Hemostatic Efficacy of Folkloric Medicinal Plant Extract in a Rat Skin Bleeding Model. Dermatol Surg 2012; 38:760-6. [DOI: 10.1111/j.1524-4725.2011.02288.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S-e350S. [PMID: 22315266 DOI: 10.1378/chest.11-2298] [Citation(s) in RCA: 1034] [Impact Index Per Article: 86.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure. METHODS The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement. RESULTS In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C). CONCLUSIONS Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Michael Mayr
- Medical Outpatient Department, University Hospital Basel, Basel, Switzerland
| | - Amir K Jaffer
- Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, OH
| | - Andrew S Dunn
- Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Regina Kunz
- Academy of Swiss Insurance Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland.
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Gupta AD, Streiff M, Resar J, Schoenberg M. Coronary stent management in elective genitourinary surgery. BJU Int 2011; 110:480-4. [PMID: 22192977 DOI: 10.1111/j.1464-410x.2011.10821.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
What's known on the subject? and What does the study add? Withdrawal of dual antiplatelet therapy before the recommended, 12 months for drug-eluting stents and 1 month for bare-metal stents increases the rate of major adverse coronary events and mortality. However, in those undergoing surgery the risk of bleeding is increased substantially for those on antiplatelet agents. Successful management in patients with coronary stents who must undergo elective or non-elective urological surgery should be a multidisciplinary decision. This article reviews the literature and recommends a protocol for clinical management of patients undergoing urological procedures after coronary stent placement. To review the literature on coronary stents and genitourinary surgery and provide a protocol for perioperative. The keywords, 'elective surgery', 'aspirin', 'clopidogrel', 'guidelines for percutaneous coronary intervention', and 'antiplatelet therapy after coronary stent placement' were used to search PubMed for any relevant articles relating to coronary stents. Recommendations were made based on the whether the procedures patients were exposed to placed them at low-, moderate- or high-bleeding risk based on the extent of the procedure. All elective procedures should be delayed for 1 month after bare-metal stent placement and 1 year after drug-eluting stent placement. In patients classified as low risk (endoscopy and laser prostatectomy), aspirin should be continued throughout the perioperative period and dual antiplatelet therapy should continue 24-48 h postoperatively, if there is no concern for active bleeding. In those classified as moderate risk (scrotal procedures, transurethral resection of bladder tumours, transurethral resection of the prostate, urinary sphincter placement) dual antiplatelet therapy should be discontinued 5-7 days before the procedure and continued within 7 days after procedure, if there is no concern for active bleeding, in consultation with cardiology. In high-risk procedures (cystectomy, nephrectomy, prostatectomy, penile prosthesis placement) dual antiplatelet therapy should be discontinued 10 days before the procedure and continued postoperatively within 7-10 days of the procedure, when there is no longer a concern for active bleeding with the assistance of a cardiologist. Coronary artery disease is becoming more prominent in our society, increasing the use of coronary stents and antiplatelet agents. With the proposed protocol, it is safe to proceed with surgical intervention in those that have adequate stent endothelialisation.
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Affiliation(s)
- Angela D Gupta
- Departments of Urology, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.
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Eichhorn W, Burkert J, Vorwig O, Blessmann M, Cachovan G, Zeuch J, Eichhorn M, Heiland M. Bleeding incidence after oral surgery with continued oral anticoagulation. Clin Oral Investig 2011; 16:1371-6. [PMID: 22160538 DOI: 10.1007/s00784-011-0649-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Accepted: 11/21/2011] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The aim of this retrospective study was to assess the incidence of postoperative hemorrhage in patients treated with coumarins without interruption of the anticoagulant treatment undergoing oral surgical procedures, mostly osteotomies for tooth removal, when compared with patients who had never been anticoagulated. MATERIAL AND METHODS Six hundred thirty-seven patients underwent 934 oral surgical procedures on an outpatient basis. The INR was measured preoperatively being 2.44 in the mean SD 0.61. Local hemostasis was carried out routinely (80%) with collagen fleece, local flap, and acrylic splint. RESULTS Of these 637 patients, 47 presented with a postoperative hemorrhage (7.4%), 15 of these 47 cases had to be treated in hospital (2.4%). All patients showed up finally with a good wound healing, no administration of blood was necessary, and local measures revealed to be sufficient in all cases except for two patients, where the preoperative anticoagulant treatment had to be changed for 6 days. The bleeding incidence in 285 patients with comparable oral surgical procedures, who had never been anticoagulated, was 0.7%. CONCLUSIONS The results suggest that oral surgical procedures can be performed safely without alteration of the oral anticoagulant treatment. CINICAL RELEVANCE: Local hemostasis with collagen fleece, local flap, and acrylic splint seems to be sufficient to prevent postoperative bleeding.
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Affiliation(s)
- Wolfgang Eichhorn
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
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Sié P, Samama CM, Godier A, Rosencher N, Steib A, Llau JV, Van der Linden P, Pernod G, Lecompte T, Gouin-Thibault I, Albaladejo P. Surgery and invasive procedures in patients on long-term treatment with direct oral anticoagulants: Thrombin or factor-Xa inhibitors. Recommendations of the Working Group on perioperative haemostasis and the French Study Group on thrombosis and haemostasis. Arch Cardiovasc Dis 2011; 104:669-76. [DOI: 10.1016/j.acvd.2011.09.001] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 09/01/2011] [Indexed: 10/15/2022]
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Theraud J, Lascarrou JB, Simonneau F, Reignier J. [Ischaemic stroke after total knee arthroplasty in patient with atrial fibrillation]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2011; 30:938-939. [PMID: 22040866 DOI: 10.1016/j.annfar.2011.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 08/24/2011] [Indexed: 05/31/2023]
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Lee JY, Chang IH, Moon YT, Kim KD, Myung SC, Kim TH, Lee JB. Effect of Prostate Biopsy Hemorrhage on MRDW and MRS Imaging. Korean J Urol 2011; 52:674-80. [PMID: 22087361 PMCID: PMC3212661 DOI: 10.4111/kju.2011.52.10.674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 08/02/2011] [Indexed: 11/24/2022] Open
Abstract
Purpose To retrospectively evaluate the effect of post-prostate-biopsy hemorrhage on the interpretation of magnetic resonance diffusion-weighted (MRDW) and magnetic resonance spectroscopic (MRS) imaging in the detection of prostate cancer. We also investigated the optimal timing for magnetic resonance examination after prostate biopsy. Materials and Methods We reviewed the records of 135 men. All patients underwent prostate magnetic resonance imaging (MRI). The prostate was divided into eight regions according to the biopsy site. Subsequently, we measured hemorrhage on apparent diffusion coefficient (ADC) values and (choline+creatinine)/citrate ([Cho+Cr]/Cit) ratios in the same regions on the MRI. We investigated the effect of hemorrhage at ADC values and (Cho+Cr)/Cit ratios on MRI and the relationship between prostate biopsy results and MRI findings. Results The mean patient age was 68.7 years and the mean time between biopsy and MRI was 23.5 days. The total hemorrhagic score demonstrated no significant associations with intervals from biopsy to MRI. Higher hemorrhagic scores were associated with higher ADC values, prostate cancer, and noncancer groups, respectively (p<0.001). ADC values were lower in tumors than in normal tissue (p<0.001), and ADC values were inversely correlated with tumor Gleason score in biopsy cores (p<0.001). However, (Cho+Cr)/Cit ratios did not exhibit any association with prostate biopsy results and hemorrhage. Conclusions Hemorrhage had no significant associations with the interval from biopsy to MRI. ADC values may help to detect prostate cancer and predict the aggressiveness of cancer; however, it is important to consider the bias effect of hemorrhage on the interpretation of MRDW imaging given that hemorrhage affects ADC values.
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Affiliation(s)
- Jong Yeon Lee
- Department of Urology, Chung-Ang University College of Medicine, Seoul, Korea
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Steib A, Hadjiat F, Skibba W, Steib JP. Focus on perioperative management of anticoagulants and antiplatelet agents in spine surgery. Orthop Traumatol Surg Res 2011; 97:S102-6. [PMID: 21852212 DOI: 10.1016/j.otsr.2011.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 04/05/2011] [Indexed: 02/02/2023]
Abstract
UNLABELLED Perioperative management of anticoagulants and antiplatelet agents is based on a compromise between the risk of hemorrhage induced by maintaining (or substituting for) them and the risk of thrombosis if they are discontinued. The hemorrhage risk in major spinal surgery is clear (50-81% incidence of transfusion), and the incidence of postoperative symptomatic spinal hematoma varies between 0.4% and 0.2% depending on whether low-molecular-weight heparin (LMWH) is prescribed postoperatively. The French Health Authority, in 2008, published guidelines on the management of patients treated with vitamin K antagonists. Treatment may be stopped without preoperative replacement in certain cases of atrial fibrillation or venous thromboembolic disease; otherwise, preoperative replacement by curative dose unfractionated heparin (UFH) or LMWH is recommended, with withdrawal early enough to avoid peroperative bleeding. Postoperative care should take account of hemorrhagic risk following surgery. The management of patients treated with antiplatelets is delicate, as maintenance is preferable in most of the situations in which they are prescribed (bare or active stenting, or secondary prevention of myocardial infarction, stroke or peripheral ischemia), although they are liable to increase the risk of perioperative hemorrhage, especially when associated to antithrombotic prophylaxis. If surgery cannot be performed under treatment continuation, the interruption should be as short as possible. New guidelines are presently being drawn up under the auspices of the French Health Authority. In both types of treatment, the strategy should be jointly determined by surgeon, anesthesiologist and cardiologist, to optimize individualized care taking account of each party's requirements, with the patient in the central role. The selected strategy should be clearly stated in the patient's file. LEVEL OF EVIDENCE V.
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Affiliation(s)
- A Steib
- Anesthesiology and Surgical Intensive Care Department, Nouvel Hôpital Civil, 1, place de l'Hôpital, 67091 Strasbourg cedex, France.
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Sié P, Samama CM, Godier A, Rosencher N, Steib A, Llau JV, van der Linden P, Pernod G, Lecompte T, Gouin-Thibault I, Albaladejo P. Chirurgies et actes invasifs chez les patients traités au long cours par un anticoagulant oral anti-IIa ou anti-Xa direct. ACTA ACUST UNITED AC 2011; 30:645-50. [DOI: 10.1016/j.annfar.2011.06.018] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 06/30/2011] [Indexed: 11/25/2022]
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