Serious adverse vascular events associated with perioperative interruption of antiplatelet and anticoagulant therapy

The role of heparin bridging in lung cancer surgery: a nationwide database analysis

PURPOSE

There is little evidence to demonstrate the impact of heparin bridging (HB) in major surgery. This study aimed to evaluate the benefits and risks of HB in lung cancer surgery by comparing HB and non-HB (NHB) groups.

METHODS

We extracted patients who were taking an anticoagulant, were diagnosed with lung cancer, and underwent lung resection between April 2014 and March 2018 from a nationwide database in Japan. We compared the HB and NHB groups to determine the benefits and risks of HB. The proportion of postoperative thromboembolism and bleeding events between the HB and NHB groups was the primary outcome. We performed propensity score matching to remove any HB assignment bias.

RESULTS

We selected 2416 patients, and among these, 1068 patients had HB and 1348 did not. Propensity score matching extracted 1500 patients: 750 with HB and 750 without HB. After matching, a Chi-square test showed no significant difference in the incidence of postoperative thromboembolism (1.5% vs 0.9%, p value = 0.343) and bleeding events (5.9% vs 4.0%, p value = 0.124) between the two groups.

CONCLUSIONS

There was no significant difference in the incidence of postoperative thromboembolism and bleeding in the patients with and those without HB.

Antiplatelet drugs: a review of pharmacology and the perioperative management of patients in oral and maxillofacial surgery

INTRODUCTION

An increasing number of patients are taking oral antiplatelet agents. As a result, there is an important patient safety concern in relation to the potential risk of bleeding complications following major oral and maxillofacial surgery. Surgeons are increasingly likely to be faced with a dilemma of either continuing antiplatelet therapy and risking serious haemorrhage or withholding therapy and risking fatal thromboembolic complications. While there are national recommendations for patients taking oral antiplatelet drugs undergoing invasive minor oral surgery, there are still no evidence-based guidelines for the management of these patients undergoing major oral and maxillofacial surgery.

METHODS

MEDLINE and EMBASE databases were searched to retrieve all relevant articles published to 31 December 2017.

FINDINGS

A brief outline of the commonly used antiplatelet agents including their pharmacology and therapeutic indications is discussed, together with the haemorrhagic and thromboembolic risks of continuing or altering the antiplatelet regimen in the perioperative period. Finally, a protocol for the management of oral and maxillofacial patients on antiplatelet agents is presented.

CONCLUSIONS

Most current evidence to guide decision making is based upon non-randomised observational studies, which attempts to provide the safest possible management of patients on antiplatelet therapy. Large randomised clinical trials are lacking.

Aspirin use and bleeding volume in skin cancer patients undergoing surgery: a randomized controlled trial

ᅟ: We investigated the occurrence of bleeding complications in patients who underwent skin tumor surgery and compared it between Aspirin users and a placebo control group. In this double blind randomized controlled trial, 32 patients who continued taking aspirin (intervention group) and 38 patients who stopped taking Aspirin (placebo group) before surgery were compared in terms of intraoprative and postoperative bleeding problems, hematoma and local signs of coagulopathy. There was no statistically significant difference in intraoprative bleeding between the study groups (P = 0.107). We concluded that continuation of Aspirin therapy had no significant effect on bleeding complications in patients who underwent skin tumor surgery.

TRIAL REGISTRATION

IRCT201602049768N5 Flow chart of the study process and its final finding.

Estimating the information gap between emergency department records of community medication compared to on-line access to the community-based pharmacy records

Objective

Errors in community medication histories increase the risk of adverse events. The objectives of this study were to estimate the extent to which access to community-based pharmacy records provided more information about prescription drug use than conventional medication histories.

Materials and methods

A prospective cohort of patients with public drug insurance who visited the emergency departments (ED) in two teaching hospitals in Montreal, Quebec was recruited. Drug lists recorded in the patients’ ED charts were compared with pharmacy records of dispensed medications retrieved from the public drug insurer. Patient and drug-related predictors of discrepancies were estimated using general estimating equation multivariate logistic regression.

Results

613 patients participated in the study (mean age 63.1 years, 59.2% women). Pharmacy records identified 41.5% more prescribed medications than were noted in the ED chart. Concordance was highest for anticoagulants, cardiovascular drugs and diuretics. Omissions in the ED chart were more common for drugs that may be taken episodically. Patients with more than 12 medications (OR 2.92, 95% CI 1.71 to 4.97) and more than one pharmacy (OR 3.85, 95% CI 1.80 to 6.59) were more likely to have omissions in the ED chart.

Discussion

The development of health information exchanges could improve the efficiency and accuracy of information about community medication histories if they enable automated access to dispensed medication records from community pharmacies, particularly for the most vulnerable populations with multiple morbidities.

Conclusions

Pharmacy records identified a substantial number of medications that were not in the ED chart. There is potential for greater safety and efficiency with automated access to pharmacy records.

Newer hemostatic agents used in the practice of dermatologic surgery

Minor postoperative bleeding is the most common complication of cutaneous surgery. Because of the commonality of this complication, hemostasis is an important concept to address when considering dermatologic procedures. Patients that have a bleeding diathesis, an inherited/acquired coagulopathy, or who are on anticoagulant/antiplatelet medications pose a greater risk for bleeding complications during the postoperative period. Knowledge of these conditions preoperatively is of the utmost importance, allowing for proper preparation and prevention. Also, it is important to be aware of the various hemostatic modalities available, including electrocoagulation, which is among the most effective and widely used techniques. Prompt recognition of hematoma formation and knowledge of postoperative wound care can prevent further complications such as wound dehiscence, infection, or skin-graft necrosis, minimizing poor outcomes.

Management of anticoagulation during dermatosurgical procedures in Germany - results from a cross-sectional study

BACKGROUND

Treatment with antiplatelet drugs (APD) and vitamin K antagonists (VKA) can be a challenge during the management of dermatosurgical interventions.

METHODS

We performed a cross-sectional study on the perioperative management of APD and VKA in dermatological private practices and clinics in Germany, using anonymized, standardized questionnaires.

RESULTS

233 responses were evaluated (response rate 37 %). Skin biopsies are performed in 82.7 % of offices and in 90.8 % of clinics despite treatment with VKA. Small excisions are done in 62.5 % of offices and 76.9 % of clinics during treatment with VKA, for large excision this applies to 11.9 % of offices and 33.8 % of clinics. Low-dose treatment with APD (#100 mg) does not hinder 80.4 % of private practices and 89.2 % of clinics to perform small excisions as well as 36.3 % and 53.8 %, respectively, to perform large excisions. Of private practitioners 67.3 % and 83.1 % of clinic-based dermato-surgeons do not consider high-dose APD a contraindication for small excisions, and 25.0 % and 41.5 %, respectively, for large excisions. Most frequently switching to heparin is performed 6-8 days prior to surgery and switching back 0-2 days after surgery.

CONCLUSIONS

Large differences in the perioperative management of anticoagulant therapy during dermatosurgical procedures have been identified. Further studies and guidelines should be developed.

Hemorrhagic complications in dermatologic surgery

The ability to recognize, manage, and, most importantly, prevent hemorrhagic complications is critical to performing dermatologic procedures that have safe and high quality outcomes. This article reviews the preoperative, intraoperative, and postoperative factors and patient dynamics that are central to preventing such an adverse outcome. Specifically, the role that anticoagulants and anti-platelet agents, hypertension, and other medical conditions play in the development of postoperative hemorrhage are discussed. In addition, this article provides practical guidelines on managing bleeding during and after surgery.

Peri-operative management of ophthalmic patients taking antithrombotic therapy

Increasing number of patients presenting for ophthalmic surgery are using oral anti-coagulant and anti-platelet therapy. The current practice of discontinuing these drugs preoperatively because of a presumed increased risk of bleeding may not be evidence-based and could pose a significant risk to the patient's health. To provide an evidence-based review on the peri-operative management of ophthalmic patients who are taking anti-thrombotic therapy. In addition, we briefly discuss the underlying conditions that necessitate the use of these drugs as well as management of the operative field in anti-coagulated patients. A semi-systematic review of literature was performed. The databases searched included MEDLINE, EMBASE, database of abstracts of reviews of effects (DARE), Cochrane controlled trial register and Cochrane systematic reviews. In addition, the bibliographies of the included papers were also scanned for evidence. The published data suggests that aspirin did not appear to increase the risk of serious postoperative bleeding in any type of ophthalmic surgery. Topical, sub-tenon, peri-bulbar and retrobulbar anaesthesia appear to be safe in patients on anti-thrombotic (warfarin and aspirin) therapy. Warfarin does not increase the risk of significant bleeding in most types of ophthalmic surgery when the INR was within the therapeutic range. Current evidence supports the continued use of aspirin and with some exceptions, warfarin in the peri-operative period. The risk of thrombosis-related complications on disruption of anticoagulation may be higher than the risk of significant bleeding by continuing its use for most types of ophthalmic surgery.

Critical Overview on the Benefits and Harms of Aspirin

Aspirin is widely used internationally for a variety of indications, with the most prominent one being that of cardiovascular disease. However, aspirin has also been proposed as a treatment option in a diverse range of conditions such as diabetes mellitus, cancer prevention, and obstetrics. In our overview, we critically appraise the current evidence from recent systematic reviews and meta-analyses covering the benefits of aspirin across these conditions. We also look at evidence that some patients may not derive benefit due to the concept of aspirin resistance. Aspirin is also associated with the potential for significant harm, principally from haemorrhagic adverse events. We critically appraise the threat of haemorrhagic complications, and weigh up these risks against that of any potential benefit.

Bleeding complications in dermatologic surgery

Although the overall incidence is low, bleeding complications in dermatologic surgery can occur and be the source of significant patient morbidity. In this article, we summarize the key aspects of preoperative assessment of patients at risk for bleeding. A review of current issues and literature regarding safe continuation of anticoagulant and antiplatelet medications in dermatologic surgery patients is also presented. In addition, principles for management of bleeding events, should they occur, are also highlighted.

[Is withdrawal of antiplatelet therapy necessary prior to skin cancer surgery?]

AIM

The aim of this study was to assess the value of discontinuing antiplatelet treatment prior to surgery for skin cancer with loss of skin of up to 10 cm in diameter. The study hypothesis postulated equivalence between discontinuation of antiplatelet therapy and continuation of these drugs during the perioperative period with regard to risk of cutaneous complications.

PATIENTS AND METHODS

This was a prospective, randomised study comparing two groups of patients on long-term antiplatelet treatment scheduled for surgery for skin carcinoma. In the first group, patients underwent surgery without change to their antiplatelet therapy while in the second, antiplatelet treatment was discontinued and substituted with either flurbiprofen or isocoagulant fractionated heparin or calcium heparin. Sixty patients took part in the study. Statistical analysis using ANOVA and Mann-Whitney non-parametric tests was performed to compare the following variables: age, sex, number of pre- and post-operative consultations, complications (haemorrhage, haematoma, separation and infection) and quality of wound healing.

RESULTS

No statistically significant difference was seen between the two groups regarding either complications or quality of wound healing.

CONCLUSION

There appear to be no rational grounds for discontinuing antiplatelet therapy in advance of skin cancer surgery involving loss of skin of up to 10 cm in diameter.

Perioperative Management of Anticoagulant Therapy during Cutaneous Surgery: 2005 Survey of Mohs Surgeons

BACKGROUND

The perioperative management of anticoagulation and antiplatelet therapy is a controversial topic in the field of dermatologic surgery. Dermasurgeons must weigh the risk of bleeding against the risk of thrombotic complications when deciding how to manage perioperative anticoagulation.

OBJECTIVE

Our aim is to present a summary of current practice in anticoagulation management perioperatively during cutaneous surgery. We compare our results to those found in a similar survey in 2002.

METHODS AND MATERIALS

A questionnaire surveying current practice in perioperative management of anticoagulant therapy was mailed to 720 dermasurgeons.

RESULTS

Thirty-eight percent of dermasurgeons responded to the questionnaire. Of the responding physicians, 87% discontinue prophylactic aspirin therapy, 37% discontinue medically necessary aspirin, 44% discontinue warfarin, 77% discontinue nonsteroidal anti-inflammatory drugs (NSAIDs), and 77% discontinue vitamin E therapy perioperatively at least some of the time. Although clopidogrel was not surveyed, 78 physicians included comments about the management of this agent.

CONCLUSION

Dermasurgeons were more likely to continue medically necessary aspirin and warfarin in 2005 compared to 2002, with the most dramatic shift evident in the management of warfarin. They were more likely to discontinue prophylactic aspirin, NSAIDs, and vitamin E. Surgeons were concerned about bleeding with the antiplatelet agent clopidogrel. More evidence-based medicine is necessary to set guidelines for the management of anticoagulation and antiplatelet therapy perioperatively.

Bleeding Complications in Dermatologic Surgery

Although the overall incidence is low, bleeding complications in dermatologic surgery can occur and be the source of significant patient morbidity. In this article, we summarize the key aspects of preoperative assessment of patients at risk for bleeding. A review of current issues and literature regarding safe continuation of anticoagulant and antiplatelet medications in dermatologic surgery patients is also presented. In addition, principles for management of bleeding events, should they occur, are also highlighted.

A prospective study of the incidence of complications associated with dermatological surgery

BACKGROUND

Dermatological surgery is a relatively new and expanding subspecialty within dermatology. Little information is available about complications in this kind of surgery in the European setting.

OBJECTIVES

The aim of this study was to assess the incidence of anaesthetic, haemorrhagic and infectious complications in dermatological surgery and to highlight the factors associated with these complications.

METHODS

Data were collected prospectively over a 3-month period for all surgical procedures performed by a network of dermatologists (n = 84 dermatologists) in France, including the excision of all benign or malignant tumours but excluding sebaceous cysts and pyodermas. Information was collected regarding dermatologists, patients, procedures and complications.

RESULTS

A total of 3788 surgical procedures were available for review; 236 complications, mostly minor, occurred in a total of 213 surgical procedures (6%), bleeding being the most common (3%). Vaso-vagal syncope was the main anaesthetic complication (51 of 54). Infectious complications occurred in 79 patients (2%). Superficial suppuration accounted for 92% of surgical site infections. Only one patient had a systemic infection. Complications requiring additional antibiotic treatment or repeat surgery accounted for only 22 cases of 3788 (1%). No statistically significant correlation was found with the characteristics of the dermatologists, especially with respect to their training or amount of surgical experience. Similarly, no link could be established between complications and surgical conditions. Multivariate analysis showed that anaesthetic or haemorrhagic complications were independent factors for infectious complications. Sex, administration of an anticoagulant or immunosuppressant, type of procedure performed and duration exceeding 24 min were independent factors for haemorrhagic complications.

CONCLUSIONS

This study shows a low rate of complications associated with dermatological surgery performed by dermatologists under local anaesthesia on an outpatient basis.

Controversies in perioperative management of blood thinners in dermatologic surgery: continue or discontinue?

BACKGROUND

The use of blood thinners has increased dramatically in recent years among the general, and especially among the elderly, population. When these patients need to undergo cutaneous surgery, the surgeon encounters the obvious problem of whether to stop these medications before surgery.

OBJECTIVE

The objective was to evaluate the risks and benefits associated with the continuation of blood thinners perioperatively in cutaneous and Mohs micrographic surgery.

METHODS

The study comprises two parts: a search of the literature in English that examined articles that related to the perioperative use of blood thinners in dermatologic surgery and a presentation of data of continuous warfarin therapy in patients who underwent Mohs surgery in our practice.

RESULTS

A total of 15 articles were published in the literature until October 2003. One article showed an increase in complications in patients treated with warfarin, but not with aspirin. All other articles showed no increase in complications during the perioperative period. Data from our practice showed that of a total of 2790 patients, 68 were operated on while taking warfarin (2.4%). Intraoperative bleeding was easily controlled and postoperative bleeding was not recorded in any of the patients.

CONCLUSION

Continuous treatment with blood thinners perioperatively in patients undergoing Mohs and cutaneous surgery is not associated with an increase in surgical complications. Discontinuation of these medications may increase the risk of cerebral and cardiovascular complications.

Antiplatelet drug discontinuation is a risk factor for ischemic stroke

Antiplatelet drugs (APD) are widely used in the prevention of ischemic cardio- and cerebrovascular diseases. The authors studied the frequency of stroke occurring after APD discontinuation, the cause of discontinuation, and the delay between APD disruption and stroke. Only 4.49% of strokes were related to a recent APD discontinuation, but all cases occurred between 6 and 10 days after drug discontinuation (p < 0.0001). This temporal pattern has biologic plausibility because the inhibited platelets circulate in the blood for about 10 days.

Cutaneous oncologic and cosmetic surgery in geriatric patients

A wide array of surgical procedures is available to geriatric patients. These interventions can enhance the appearance of patients and facilitate the removal of skin cancers. Pre-existing medical conditions of geriatric patients must be considered comprehensively when selecting and performing cutaneous surgical procedures. Many older patients suffer from a variety of diseases and take a variety of medications and herbal supplements to ameliorate the consequences of such diseases. In general, skin surgery can be performed safely on even very old patients, provided precautions are followed. The biopsychosocial well-being and essence of patients must also be addressed when performing dermatologic surgery. If patients are treated holistically and comprehensively, their surgical experience can be enhanced and their health and appearance improved.