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Pappas MA, Feldman LS, Auerbach AD. Coronary Disease Risk Prediction, Risk Reduction, and Postoperative Myocardial Injury. Med Clin North Am 2024; 108:1039-1051. [PMID: 39341612 DOI: 10.1016/j.mcna.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2024]
Abstract
For patients considering surgery, the preoperative evaluation allows physicians to identify and treat acute cardiac conditions before less-urgent surgery, predict the benefits and harms of a proposed surgery, and make temporary management changes to reduce operative risk. Multiple risk prediction tools are reasonable for use in estimating perioperative cardiac risk, but management changes to reduce risk have proven elusive. For all but the most urgent surgical procedures, patients with active coronary syndromes or decompensated heart failure should have surgery postponed.
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Affiliation(s)
- Matthew A Pappas
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA; Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, USA; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Leonard S Feldman
- Departments of Medicine and Pediatrics, Division of Hospital Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Andrew D Auerbach
- Department of Hospital Medicine, University of California, San Francisco, CA, USA
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2
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Geerts WH, Jeong E, Robinson LR, Khosravani H. Venous Thromboembolism Prevention in Rehabilitation: A Review and Practice Suggestions. Am J Phys Med Rehabil 2024; 103:934-948. [PMID: 38917440 DOI: 10.1097/phm.0000000000002570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
ABSTRACT Venous thromboembolism is a frequent complication of acute hospital care, and this extends to inpatient rehabilitation. The timely use of appropriate thromboprophylaxis in patients who are at risk is a strong, evidence-based patient safety priority that has reduced clinically important venous thromboembolism, associated mortality and costs of care. While there has been extensive research on optimal approaches to venous thromboembolism prophylaxis in acute care, there is a paucity of high-quality evidence specific to patients in the rehabilitation setting, and there are no clinical practice guidelines that make recommendations for (or against) thromboprophylaxis across the broad spectrum of rehabilitation patients. Herein, we provide an evidence-informed review of the topic with practice suggestions. We conducted a series of literature searches to assess the risks of venous thromboembolism and its prevention related to inpatient rehabilitation as well as in major rehabilitation subgroups. Mobilization alone does not eliminate the risk of venous thromboembolism after another thrombotic insult. Low molecular weight heparins and direct oral anticoagulants are the principal current modalities of thromboprophylaxis. Based on the literature, we make suggestions for venous thromboembolism prevention and include an approach for consideration by rehabilitation units that can be aligned with local practice.
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Affiliation(s)
- William H Geerts
- From the Thromboembolism Program, Sunnybrook Health Sciences Centre (WHG); Department of Medicine, University of Toronto, Toronto, ON, Canada (WHG); Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada (EJ); Sunnybrook Health Sciences Centre, Toronto, ON, Canada (LRR, HK); Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada (LRR); and Division of Neurology, University of Toronto, Toronto, ON, Canada (HK)
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Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, Chow B, Dakik HA, Eisenstein EL, Gerhard-Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G, Merli GJ, Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024:S0735-1097(24)07611-3. [PMID: 39320289 DOI: 10.1016/j.jacc.2024.06.013] [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] [Indexed: 09/26/2024]
Abstract
AIM The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.
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Watanabe I, Hattori A, Fukui M, Matsunaga T, Takamochi K, Suzuki K. Prior coronary stent does not exclude major pulmonary resection regardless of antiplatelet therapy. Surg Today 2024:10.1007/s00595-024-02933-8. [PMID: 39245749 DOI: 10.1007/s00595-024-02933-8] [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: 08/20/2023] [Accepted: 11/26/2023] [Indexed: 09/10/2024]
Abstract
PURPOSE We assessed the safety of general thoracic surgery in patients with prior coronary stents undergoing lung resection, based on differences in perioperative antiplatelet therapy management. METHODS We retrospectively examined 150 patients with coronary artery stents who underwent pulmonary resection between July 2009 and July 2018. The impact of the antiplatelet agent on thoracic surgery safety was assessed by comparing perioperative outcomes, including major adverse cardiac and cerebrovascular events, among the discontinued antiplatelet therapy (group D), heparin bridging (group H), and continuous antiplatelet therapy (group C) groups. RESULTS Groups D, H, and C included twenty-four, eighty-four, and forty-two patients, respectively. Second-generation drug-eluting stents were used in > 50% of the patients. No significant differences were found in the estimated blood loss, transfusion rate, or operative duration. Major adverse cardiac and cerebrovascular events occurred in four (2.7%) patients, which was comparable among the groups. In group H, postoperative heart failure and transient ischemic attack with stroke occurred in one patient each. Major bleeding occurred in two (4.7%) patients in group C. CONCLUSIONS Pulmonary resection surgical outcomes in patients with coronary artery stents were feasible regardless of antiplatelet therapy continuation. However, discontinuing dual-antiplatelet or single-antiplatelet therapy in such patients may be reasonable because this generation of drug-eluting stents has a higher safety profile than bare-metal and first-generation drug-eluting stents.
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Affiliation(s)
- Isamu Watanabe
- Department of General Thoracic Surgery, Juntendo University School of Medicine, 1-3 Hongo 3-Chome, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Aritoshi Hattori
- Department of General Thoracic Surgery, Juntendo University School of Medicine, 1-3 Hongo 3-Chome, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Mariko Fukui
- Department of General Thoracic Surgery, Juntendo University School of Medicine, 1-3 Hongo 3-Chome, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Takeshi Matsunaga
- Department of General Thoracic Surgery, Juntendo University School of Medicine, 1-3 Hongo 3-Chome, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Kazuya Takamochi
- Department of General Thoracic Surgery, Juntendo University School of Medicine, 1-3 Hongo 3-Chome, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Kenji Suzuki
- Department of General Thoracic Surgery, Juntendo University School of Medicine, 1-3 Hongo 3-Chome, Bunkyo-Ku, Tokyo, 113-8431, Japan.
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Chang MG, Bittner EA. Comparison of societal guidance on perioperative management of glucagon-like peptide-1 receptor agonists: implications for clinical practice and future investigations. Can J Anaesth 2024; 71:1302-1315. [PMID: 39187641 DOI: 10.1007/s12630-024-02810-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/24/2024] [Accepted: 05/26/2024] [Indexed: 08/28/2024] Open
Abstract
PURPOSE The use of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) by patients undergoing surgery and procedures requiring anesthesia has become a topic of significant concern for perioperative providers because of the potential increased risk of aspiration resulting from the medication's effect of delaying gastric emptying. There is currently a lack of high-quality data regarding the safety of GLP-1 RAs in patients undergoing surgery, which has led to variations in practice. SOURCE We performed an internet search of society-endorsed statements and guidelines related to perioperative management of GLP-1 RAs, focusing on the top 20 countries with the largest anesthesiology societies determined by membership data from the World Federation of Societies of Anesthesiologists. We excluded articles and websites that were not in English. PRINCIPAL FINDINGS Our search revealed endorsed statements from fourteen major anesthesiology, endocrinology, and gastroenterology societies. There was considerable variation between societies in the recommendations and guidance for withholding these medications before surgery, the duration of withholding, assessment of the need for avoiding deep sedation or general anesthesia, use of rapid sequence intubation, need for prolonged fasting periods and clear fluid before a nil per os period, recognition of signs and symptoms for aspiration risk, the management of glucose in the perioperative period, and the use of point-of-care ultrasound for risk assessment. CONCLUSION Society-endorsed statements and guidelines provide varying recommendations on the perioperative management of GLP-1 RAs. The insights gained from this comparative analysis may help guide clinical practice, develop institutional practice guidelines, and direct future research efforts.
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Affiliation(s)
- Marvin G Chang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Massachusetts General Hospital, 55 Fruit Street, White 437, Boston, MA, USA.
| | - Edward A Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Angiolillo DJ. Management of Antiplatelet Therapy After Coronary Stenting in Patients Requiring Noncardiac Surgery. J Am Coll Cardiol 2024:S0735-1097(24)08251-2. [PMID: 39222897 DOI: 10.1016/j.jacc.2024.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA.
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Gupta AK, Kovoor JG, Leslie A, Litwin P, Stretton B, Zaka A, Kovoor P, Bacchi S, Bennetts JS, Maddern GJ. To be or not to be on: aspirin and coronary artery bypass graft surgery. Front Cardiovasc Med 2024; 11:1451337. [PMID: 39253391 PMCID: PMC11381263 DOI: 10.3389/fcvm.2024.1451337] [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: 06/19/2024] [Accepted: 07/31/2024] [Indexed: 09/11/2024] Open
Abstract
Aspirin's role in secondary prevention for patients with known coronary artery disease (CAD) is well established, validated by numerous landmark trials over the past several decades. However, its perioperative use in coronary artery bypass graft (CABG) surgery remains contentious due to the delicate balance between the risks of thrombosis and bleeding. While continuation of aspirin in patients undergoing CABG following acute coronary syndrome is widely supported due to the high risk of re-infarction, the evidence is less definitive for elective CABG procedures. The literature indicates a significant benefit of aspirin in reducing cardiovascular events in CAD patients, yet its impact on perioperative outcomes in CABG surgery is less clear. Some studies suggest increased bleeding risks without substantial improvement in cardiac outcomes. Specific to elective CABG, evidence is mixed, with some data indicating no significant difference in thrombotic or bleeding complications whether aspirin is continued or withheld preoperatively. Advancements in pharmacological therapies and perioperative care have evolved significantly since the initial aspirin trials, raising questions about the contemporary relevance of earlier findings. Individualized patient assessments and the development of risk stratification tools are needed to optimize perioperative aspirin use in CABG surgery. Further research is essential to establish clearer guidelines and improve patient outcomes. The objective of this review is to critically evaluate the existing evidence into the optimal management of perioperative aspirin in elective CABG patients.
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Affiliation(s)
- Aashray K Gupta
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Joshua G Kovoor
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
- Australian Safety and Efficacy Register of New Interventional Procedures-Surgical, Royal Australasian College of Surgeons, Adelaide, SA, Australia
| | - Alasdair Leslie
- Department of Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Peter Litwin
- Department of Medicine, Gold Coast University Hospital, Southport, QLD, Australia
| | - Brandon Stretton
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
- Department of Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Ammar Zaka
- Department of Medicine, Gold Coast University Hospital, Southport, QLD, Australia
| | - Pramesh Kovoor
- Department of Cardiology, Westmead Hospital, Westmead, NSW, Australia
| | - Stephen Bacchi
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Jayme S Bennetts
- School of Medicine, Monash University, Melbourne, VIC, Australia
- Department of Cardiothoracic Surgery, Victorian Heart Hospital, Melbourne, NSW, Australia
| | - Guy J Maddern
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
- Australian Safety and Efficacy Register of New Interventional Procedures-Surgical, Royal Australasian College of Surgeons, Adelaide, SA, Australia
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, SA, Australia
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Lyons MD, Pope B, Alexander J. Perioperative Management of Antithrombotic Therapy. JAMA 2024; 332:420-421. [PMID: 38900436 DOI: 10.1001/jama.2024.5880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
This JAMA Clinical Guidelines Synopsis summarizes the American College of Chest Physicians’ 2022 guideline on perioperative management of patients taking oral anticoagulation or antiplatelet therapy who are undergoing an elective surgery or procedure.
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Affiliation(s)
- Maureen D Lyons
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
| | - Bailey Pope
- Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, Portland
| | - Jason Alexander
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, Illinois
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Yang J, Wang K, Han C, Liu Q, Zhang S, Wu J, Jiang P, Yang S, Guo R, Mo S, Yang Y, Zhang J, Liu Y, Cao Y, Wang S. Preoperative antiplatelet therapy may be a risk factor for postoperative ischemic complications in intracranial hemorrhage patients. Int J Neurosci 2024; 134:899-905. [PMID: 36503400 DOI: 10.1080/00207454.2022.2157724] [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: 01/14/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hemorrhage (ICH) patients are still at risk of postoperative ischemic complications (PICs) after surgery. In addition, the proportion of patients receiving antiplatelet therapy (APT) in ICH patients increased significantly with age. This study aims to evaluate the impact of preoperative antiplatelet therapy on PICs in ICH patients. METHODS This is a cohort study that retrospectively analyzed the data of ICH patients who underwent surgical treatment. PICs rate was compared between patients with preoperative ATP and those without preoperative ATP. Univariate and multivariate analyses were conducted to evaluate the impact of preoperative APT on PICs. In addition, Kaplan-Meier method was used for survival analysis and the impact of PICs on patients' postoperative outcomes was evaluated. RESULTS A total of 216 patients were included in this study. There were 47 patients (21.76%) with preoperative APT; 169 patients (78.24%) without preoperative APT. The incidence of PICs in the APT group was significantly higher when compared with that in the nAPT group (36.17% vs. 20.71%, p = 0.028<0.05). Furthermore, significant differences were both observed in multivariate analysis (p = 0.035<0.05) and survival analysis (log rank χ2 = 5.415, p = 0.020<0.05). However, there was no significant difference between the outcomes of patients suffering from PICs and that of patients not suffering from PICs (p = 0.377 > 0.05). CONCLUSIONS In conclusion, preoperative APT may be a risk factor for PICs in ICH patients undergoing surgical treatment significantly.
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Affiliation(s)
- Junhua Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Chao Han
- Qingdao Central Hospital Group, Qingdao, P. R. China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jiaming Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
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Houben AM, Crepy M, Senard M, Bonhomme V, Tchana-Sato V, Hans G. Preoperative continuation of aspirin before isolated heart valve surgery and postoperative bleeding and transfusion: a single-center retrospective study. Acta Chir Belg 2024; 124:274-280. [PMID: 38146908 DOI: 10.1080/00015458.2023.2298097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/18/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND The risks and benefits of preoperative aspirin continuation in patients undergoing isolated heart valve replacement surgery are unclear. We investigated the effect of aspirin continuation on the risk of bleeding and transfusion in these patients. METHODS In this single center, retrospective study, among 474 adult patients who underwent isolated heart valve surgery between April 2013 and June 2018, 269 continued aspirin within 5 days before surgery (aspirin group) and 205 patients did not take or stopped aspirin no later than 5 days before surgery (non-aspirin group). The chi-square test, the Mann-Whitney U-test, and the Student's T-test were used to compare data between the groups. Univariate and Multivariate logistic regressions were used to assess crude and adjusted relationships between outcome and exposure. RESULTS The primary outcome, red blood cell (RBC) transfusion, occurred in 59 patients (22%) of the aspirin group and in 24 patients (12%) of the non-aspirin group (p = 0.004). After adjustment for confounding factors, continuation of aspirin was no longer associated with RBC transfusion (aOR1.8;95%CI,0.98-3.2;p = 0.06). The amount of allogenic blood products, the incidence of surgical re-exploration for bleeding, the volume of re-transfused cell-saved blood, and the cumulative chest tube drainage during the first 24 postoperative hours were similar between groups. CONCLUSION Preoperative continuation of aspirin in patients undergoing isolated heart valve surgery is neither associated with a higher incidence of RBC transfusion, nor with larger perioperative blood loss, or more frequent surgical revision for bleeding. TRIAL REGISTRATION Clinicaltrials.gov (NCT05151796).
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Affiliation(s)
- Alan M Houben
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
| | - Margaux Crepy
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
| | - Marc Senard
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Vincent Tchana-Sato
- Department of Cardiovascular Surgery, Liege University Hospital, Liege, Belgium
| | - Gregory Hans
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
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Swan D, Turner R, Douketis J, Thachil J. How to undertake procedures while on antiplatelet agents: a hematologist's view. Res Pract Thromb Haemost 2024; 8:102539. [PMID: 39318772 PMCID: PMC11419924 DOI: 10.1016/j.rpth.2024.102539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/28/2024] [Accepted: 06/27/2024] [Indexed: 09/26/2024] Open
Abstract
Cardiovascular diseases (CVDs) are the leading cause of mortality globally while also contributing to excess health system costs. Significant advancements have been made in the understanding and prevention of deaths from CVD. In addition to risk factor modifications, one of the key developments in this area is the appropriate prescribing of antiplatelet medications for secondary prevention of CVD. With the advent of vascular devices, there has been an increased use of potent antiplatelet agents to mitigate thrombosis risk. A well-recognized, albeit rare complication of antiplatelet drugs is the heightened risk of bleeding. This adverse effect is particularly relevant when a patient receiving these medications may require an urgent surgery. In addition, for elective surgeries, although these drugs can be withheld, there may be some situations when interruption of antiplatelet agents, even for short duration, may lead to thrombotic events. There are no robust guidelines on how to manage these clinical scenarios, although there have been some important studies published recently in this area. In this review, we provide our approach to patients on antiplatelet drugs who may require urgent surgeries or surgical interventions.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, Austin Health, Melbourne, Victoria, Australia
| | - Robert Turner
- Department of Intensive Care, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - James Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, Ontario, Canada
| | - Jecko Thachil
- Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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12
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Douketis JD, Yi Q, Bhatt DL, Muehlhofer E, Wang MK, Connolly S, Yusuf S, Maggioni AP, Eikelboom JW. Perioperative management and outcomes in patients receiving low-dose rivaroxaban and/or aspirin: a subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial. J Thromb Haemost 2024; 22:2227-2233. [PMID: 38729576 DOI: 10.1016/j.jtha.2024.03.030] [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: 01/08/2024] [Revised: 03/11/2024] [Accepted: 03/27/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND No study has investigated the perioperative management and clinical outcomes in patients who are receiving rivaroxaban 2.5 mg twice a day and acetylsalicylic acid (ASA) 81 to 100 mg daily. OBJECTIVE To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. METHODS Subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial was performed to assess perioperative management and clinical outcomes in patients with stable coronary or peripheral artery disease who were randomized to receive rivaroxaban 2.5 mg twice a day plus ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA 100 mg daily. Patients studied required a surgery/procedure during the trial. The study outcomes, which included myocardial infarction, angina, stroke, acute limb ischemia, bleeding, and death, were assessed according to treatment allocation. RESULTS There were 2632 patients studied (mean age, 68 years; 80% male) who had a surgery/procedure, comprising percutaneous coronary interventions (∼43%), carotid or other arterial angioplasty (∼15%), pacemaker or internal cardiac defibrillator implantation (∼9%), and coronary artery bypass graft surgery (∼7%). Perioperative study drug management varied, with about one-third of patients not interrupting study drug and the remainder interrupting it between 1 and ≥10 days preprocedure. The incidences of adverse outcomes across treatment groups were 12.7% to 15.3% for myocardial ischemia, 0.8% to 1.2% for stroke, 0.1% to 0.2% for venous thromboembolism, and 3.1% to 4.2% for any bleeding. There was no statistically significant difference in outcome rates across treatment groups. CONCLUSION In patients in the COMPASS trial who required a surgery/procedure, there was no significant difference in perioperative adverse outcomes whether patients were receiving rivaroxaban 2.5 mg twice a day and ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA alone.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.
| | - Qilong Yi
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Deepak L Bhatt
- Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | | | - Michael K Wang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Stuart Connolly
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Salim Yusuf
- Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Aldo P Maggioni
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Zhou Z, Webb KL, Nelson MR, Woods RL, Ernst ME, Murray AM, Chan AT, Tonkin A, Reid CM, Orchard SG, Kirpach B, Shah RC, Stocks N, Broder JC, Wolfe R. Short- and long-term impact of aspirin cessation in older adults: a target trial emulation. BMC Med 2024; 22:306. [PMID: 39075484 PMCID: PMC11287830 DOI: 10.1186/s12916-024-03507-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 07/01/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND The net benefit of aspirin cessation in older adults remains uncertain. This study aimed to use observational data to emulate a randomized trial of aspirin cessation versus continuation in older adults without cardiovascular disease (CVD). METHODS Post hoc analysis using a target trial emulation framework applied to the immediate post-trial period (2017-2021) of a study of low-dose aspirin initiation in adults aged ≥ 70 years (ASPREE; NCT01038583). Participants from Australia and the USA were included if they were free of CVD at the start of the post-trial intervention period (time zero, T0) and had been taking open-label or randomized aspirin immediately before T0. The two groups in the target trial were as follows: aspirin cessation (participants who were taking randomized aspirin immediately before T0; assumed to have stopped at T0 as instructed) versus aspirin continuation (participants on open-label aspirin at T0 regardless of their randomized treatment; assumed to have continued at T0). The outcomes after T0 were incident CVD, major adverse cardiovascular events (MACE), all-cause mortality, and major bleeding during 3, 6, and 12 months (short-term) and 48 months (long-term) follow-up. Hazard ratios (HRs) comparing aspirin cessation to continuation were estimated from propensity-score (PS) adjusted Cox proportional-hazards regression models. RESULTS We included 6103 CVD-free participants (cessation: 5427, continuation: 676). Over both short- and long-term follow-up, aspirin cessation versus continuation was not associated with elevated risk of CVD, MACE, and all-cause mortality (HRs, at 3 and 48 months respectively, were 1.23 and 0.73 for CVD, 1.11 and 0.84 for MACE, and 0.23 and 0.79 for all-cause mortality, p > 0.05), but cessation had a reduced risk of incident major bleeding events (HRs at 3 and 48 months, 0.16 and 0.63, p < 0.05). Similar findings were seen for all outcomes at 6 and 12 months, except for a lowered risk of all-cause mortality in the cessation group at 12 months. CONCLUSIONS Our findings suggest that deprescribing prophylactic aspirin might be safe in healthy older adults with no known CVD.
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Affiliation(s)
- Zhen Zhou
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Katherine L Webb
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Robyn L Woods
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Michael E Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Iowa, Iowa, IA, USA
- Department of Family Medicine, Carver College of Medicine, The University of Iowa, Iowa, IA, USA
| | - Anne M Murray
- Division of Geriatrics, Department of Medicine Hennepin HealthCare, Berman Centre for Outcomes and Clinical Research, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew Tonkin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- School of Population Health, Curtin University, Perth, WA, Australia
| | - Suzanne G Orchard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Brenda Kirpach
- Division of Geriatrics, Department of Medicine Hennepin HealthCare, Berman Centre for Outcomes and Clinical Research, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Raj C Shah
- Department of Family & Preventive Medicine and the Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
| | - Nigel Stocks
- Discipline of General Practice, University of Adelaide, Adelaide, SA, Australia
| | - Jonathan C Broder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
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14
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Borges FK, Guerra-Farfan E, Bhandari M, Patel A, Slobogean G, Feibel RJ, Sancheti PK, Tiboni ME, Balaguer-Castro M, Tandon V, Tomas-Hernandez J, Sigamani A, Sigamani A, Szczeklik W, McMahon SJ, Ślęczka P, Ramokgopa MT, Adinaryanan S, Umer M, Jenkinson RJ, Lawendy A, Popova E, Nur AN, Wang CY, Vizcaychipi M, Biccard BM, Ofori S, Spence J, Duceppe E, Marcucci M, Harvey V, Balasubramanian K, Vincent J, Tonelli AC, Devereaux PJ. Myocardial Injury in Patients with Hip Fracture: A HIP ATTACK Randomized Trial Substudy. J Bone Joint Surg Am 2024:00004623-990000000-01161. [PMID: 39052767 DOI: 10.2106/jbjs.23.01459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
BACKGROUND Myocardial injury after a hip fracture is common and has a poor prognosis. Patients with a hip fracture and myocardial injury may benefit from accelerated surgery to remove the physiological stress associated with the hip fracture. This study aimed to determine if accelerated surgery is superior to standard care in terms of the 90-day risk of death in patients with a hip fracture who presented with an elevated cardiac biomarker/enzyme measurement at hospital arrival. METHODS The HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) trial was a randomized controlled trial designed to determine whether accelerated surgery for hip fracture was superior to standard care in reducing death or major complications. This substudy is a post-hoc analysis of 1392 patients (from the original study of 2970 patients) who had a cardiac biomarker/enzyme measurement (>99.9% had a troponin measurement and thus "troponin" is the term used throughout the paper) at hospital arrival. The primary outcome was all-cause mortality. The secondary composite outcome included all-cause mortality and non-fatal myocardial infarction, stroke, and congestive heart failure 90 days after randomization. RESULTS Three hundred and twenty-two (23%) of the 1392 patients had troponin elevation at hospital arrival. Among the patients with troponin elevation, the median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] = 5 to 13) in the accelerated surgery group and 29 hours (IQR = 19 to 52) in the standard care group. Patients with troponin elevation had a lower risk of mortality with accelerated surgery compared with standard care (17 [10%] of 163 versus 36 [23%] of 159; hazard ratio [HR] = 0.43 [95% confidence interval (CI) = 0.24 to 0.77]) and a lower risk of the secondary composite outcome (23 [14%] of 163 versus 47 [30%] of 159; HR = 0.43 [95% CI = 0.26 to 0.72]). CONCLUSIONS One in 5 patients with a hip fracture presented with myocardial injury. Accelerated surgery resulted in a lower mortality risk than standard care for these patients; however, these findings need to be confirmed. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Flavia K Borges
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ernesto Guerra-Farfan
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Ameen Patel
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gerard Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Robert J Feibel
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital - General Campus, University of Ottawa, Ottawa, Ontario, Canada
| | - Parag K Sancheti
- Sancheti Institute for Orthopaedics & Rehabilitation & PG College, Pune, India
| | - Maria E Tiboni
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mariano Balaguer-Castro
- Department of Orthopaedic Surgery and Traumatology, Parc Taulí Hospital Universitario, Sabadell, Spain
- Department of Orthopaedic Surgery and Traumatology, Hospital Clinic Barcelona, Barcelona, Spain
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Alen Sigamani
- Department of Orthopedics, Government TD Medical College, Vandanam, India
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | | | - Pawel Ślęczka
- Independent Public Health Care Center, SPZOZ Myślenice, Myślenice, Poland
| | - Mmampapatla T Ramokgopa
- Division of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - S Adinaryanan
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Masood Umer
- Department of Surgery, Aga Khan University, Karachi City, Pakistan
| | - Richard J Jenkinson
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario Canada
| | - Abdel Lawendy
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | - Ekaterine Popova
- The Sant Pau Biomedical Research Institute, Barcelona, Spain
- Iberoamerican Cochrane Center, Barcelona, Spain
| | - Aamer Nabi Nur
- Department of Orthopaedic Surgery, Shifa International Hospital, Islamabad, Pakistan
| | - Chew Yin Wang
- Department of Anaesthesiology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Marcela Vizcaychipi
- Section of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Western Cape, South Africa
| | - Sandra Ofori
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Spence
- Department of Anesthesia and Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Emmanuelle Duceppe
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Maura Marcucci
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Valerie Harvey
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Kumar Balasubramanian
- Department of Statistics, Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada
| | - Jessica Vincent
- Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada
| | - Ana Claudia Tonelli
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, Unisinos University, São Leopoldo, Brazil
- Internal Medicine Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - P J Devereaux
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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15
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Hong HJ, Park JH, Park S, Park IK, Kang CH, Kim YT. Safety of Perioperative Maintenance of Antiplatelet Agents in Elderly Patients Undergoing Lung Cancer Surgery. J Chest Surg 2024; 57:342-350. [PMID: 38472123 PMCID: PMC11240096 DOI: 10.5090/jcs.23.155] [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: 11/06/2023] [Revised: 01/10/2024] [Accepted: 01/23/2024] [Indexed: 03/14/2024] Open
Abstract
Background The maintenance of antiplatelet therapy increases the risk of bleeding during lung cancer surgery. Conversely, the perioperative interruption of antiplatelet therapy may result in serious thrombotic complications. This study aimed to investigate the safety of continuing antiplatelet therapy in the context of lung cancer surgery. Methods We retrospectively reviewed a cohort of 498 elderly patients who underwent surgery for lung cancer. These patients were categorized into 2 groups: group N, which did not receive antiplatelet therapy, and group A, which did. Group A was subsequently subdivided into group Am, where antiplatelet therapy was maintained, and group Ai, where antiplatelet therapy was interrupted. We compared the incidence of bleeding-related and thrombotic complications across the 3 groups. Results There were 387 patients in group N and 101 patients in group A (Ai: 70, Am: 31). No significant differences were found in intraoperative blood loss, thoracotomy conversion rates, transfusion requirements, volume of chest tube drainage, or reoperation rates for bleeding control between groups N and A or between groups Am and Ai. The duration of hospital stay was longer for group A compared to group N (7 days vs. 6 days, p=0.005), but there was no significant difference between groups Ai and Am. The incidence of cardiovascular or cerebrovascular complications did not differ significantly between groups Ai and Am. However, group Ai included a severe case of in-hospital ST-elevation myocardial infarction. Conclusion The maintenance of antiplatelet therapy was found to be safe in terms of perioperative bleeding and thrombotic complications in elderly lung cancer surgery patients.
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Affiliation(s)
- Hee Ju Hong
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Hyeon Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Samina Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - In Kyu Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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16
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Fujikawa T, Hasegawa S, Takahashi R, Naito S, Kaihara S, Uryuhara K, Hirata K, Tamura T, Terajima H, Kawai T, Okabe H, Machimoto T, Tanaka H, Honma S, Furumoto K, Honda G, Uemura S, Nishitai R, Hida K, Aoyama R, Wada S, Hirose T, Obama K. Management of Patients Receiving Antiplatelet Therapy During Gastroenterological Surgery: A Multicenter Prospective Cohort Study (GSATT). Ann Surg 2024; 280:82-90. [PMID: 37870247 DOI: 10.1097/sla.0000000000006136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
OBJECTIVE This study aimed to evaluate the effect of continuing preoperative aspirin monotherapy on surgical outcomes in patients receiving antiplatelet therapy (APT). BACKGROUND The effectiveness of continuing preoperative aspirin monotherapy in patients undergoing APT in preventing thromboembolic consequences is mostly unknown. METHODS This prospective multicenter cohort study on the Safety and Feasibility of Gastroenterological Surgery in Patients Undergoing Antithrombotic Therapy (GSATT study) conducted at 14 clinical centers enrolled and screened patients between October 2019 and December 2021. The participants (n=1170) were assigned to the continued-APT group, discontinued-APT group, or non-APT group, and the surgical outcomes of each group were compared. Propensity score matching was performed between the continued and discontinued-APT groups to investigate the effect of continuing preoperative aspirin therapy on thromboembolic complications. RESULTS The rate of thromboembolic complications in the continued-APT group was substantially lower than that in the non-APT or discontinued-APT groups (0.5% vs 2.6% vs. 2.9%; P =0.027). Multivariate investigation of the entire cohort revealed that discontinuation of APT ( P <0.001) and chronic anticoagulant use ( P <0.001) were independent risk factors for postoperative thromboembolism. The post-matching evaluation demonstrated that the rates of thromboembolic complications were significantly different between the continued and discontinued-APT groups (0.6% vs 3.3%; P =0.012). CONCLUSIONS APT discontinuation after elective gastroenterological surgery increases the risk of thromboembolic consequences, whereas continuing preoperative aspirin greatly reduces this risk. The continuation of preoperative aspirin therapy in APT-received patients is considered one of the best alternatives for preventing thromboembolism during elective gastroenterological surgery.
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Affiliation(s)
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University, Fukuoka, Japan
| | - Ryo Takahashi
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan
| | - Shigetoshi Naito
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
- Department of Gastroenterological Surgery, Fukuoka University, Fukuoka, Japan
| | - Satoshi Kaihara
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kenji Uryuhara
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Keiji Hirata
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshihisa Tamura
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hiroaki Terajima
- Department of Gastroenterological Surgery and Oncology, Kitano Hospital Medical Research Institute, Osaka, Japan
| | - Takayuki Kawai
- Department of Gastroenterological Surgery and Oncology, Kitano Hospital Medical Research Institute, Osaka, Japan
| | - Hiroshi Okabe
- Department of Gastroenterological Surgery, New Tokyo Hospital, Matsudo, Japan
| | | | - Hirokazu Tanaka
- Department of Gastrointestinal Surgery, Tenri Hospital, Tenri, Japan
| | - Shusaku Honma
- Department of Surgery, Kobe City Medical Center West Hospital, Kobe, Japan
| | | | - Goro Honda
- Department of Surgery, Institute of Gastroenterology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Shuichiro Uemura
- Department of Surgery, Institute of Gastroenterology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Ryuta Nishitai
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan
| | - Koya Hida
- Department of Gastrointestinal Surgery, Kyoto University, Kyoto, Japan
| | - Ryuhei Aoyama
- Department of Gastrointestinal Surgery, Kyoto University, Kyoto, Japan
| | - Seidai Wada
- Department of Surgery, Toyooka Hospital, Toyooka, Japan
| | - Tetsuro Hirose
- Department of Surgery, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Kazutaka Obama
- Department of Gastrointestinal Surgery, Kyoto University, Kyoto, Japan
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17
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Matsuoka T, Fujikawa T, Kawamura Y, Hasegawa S. Impact of Preoperative Continued Aspirin Therapy on Perioperative Bleeding Complications in Patients Undergoing Gastrectomy for Malignancy. Cureus 2024; 16:e65303. [PMID: 39184653 PMCID: PMC11343640 DOI: 10.7759/cureus.65303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2024] [Indexed: 08/27/2024] Open
Abstract
Background The question of whether antiplatelet therapy (APT) should be discontinued prior to gastrectomy is controversial. In this study, we investigated the impact of continuing aspirin preoperatively on perioperative bleeding and thromboembolic complications in patients receiving gastrectomy for malignancy. Methods The study cohort comprised 1001 patients with malignant gastric tumors who had undergone gastrectomy between 2005 and 2021. This study excludes emergency surgery. The patients were allocated to the following three groups: those who continued aspirin monotherapy prior to surgery (cAPT group), those who stopped receiving it seven days prior to surgery (dAPT group), and those who did not take APT at any stage (non-APT group). The differences between the groups in intraoperative and postoperative complications, such as bleeding and thromboembolism, were examined. Results The non-APT group comprised 682 patients, the dAPT group had 164, and the cAPT group had 155. There were 22 bleeding events (2.2%) in the whole cohort, 11 (1.1%) of which occurred in the non-APT group, six (3.7%) in the dAPT group, and five (3.2%) in the cAPT group. The differences between the three groups were not significant in terms of bleeding complications. There were 10 (1.0%) thromboembolic events in the whole cohort, five (0.7%) of which occurred in the non-APT group, four (2.4%) in the dAPT group, and one (0.6%) in the cAPT group. The differences between the three groups were not significant in terms of thromboembolic complications. In a multivariate analysis of the whole cohort, intraoperative blood loss (≥1000 mL) (p < 0.001, odds ratio (OR) = 11.8) and multidrug APT (p < 0.001, OR = 7.8) were both independent predictors of bleeding complications. However, continuing to take aspirin before surgery was not a risk factor for bleeding complications. Conclusions In patients with malignant gastric tumors, preoperative continuation of aspirin monotherapy has no impact on either intraoperative or postoperative bleeding. Gastrectomy can be performed safely, even in patients who continue aspirin treatment.
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Affiliation(s)
| | | | | | - Suguru Hasegawa
- Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka, JPN
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18
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Impact of postoperative cardiovascular complications on 30-day mortality after major abdominal surgery: an international prospective cohort study. Anaesthesia 2024; 79:715-724. [PMID: 38303634 DOI: 10.1111/anae.16220] [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: 11/27/2023] [Indexed: 02/03/2024]
Abstract
Cardiovascular complications after major surgery are associated with increases in morbidity and mortality. There is confusion over definitions of cardiac injury or complications, and variability in the assessment and management of patients. This international prospective cohort study aimed to define the incidence and timing of these complications and to investigate their impact on 30-day all-cause mortality. We performed a prospective, international cohort study between January 2022 and May 2022. Data were collected on consecutive patients undergoing major abdominal surgery in 446 hospitals from 28 countries across Europe. The primary outcome measure was cardiovascular complications as defined by the Standardised Endpoints for Perioperative Medicine-Core Outcome Measures for Perioperative and Anaesthetic Care initiative up to 30 days after surgery. The secondary outcome was 30-day postoperative mortality. This study included 24,203 patients, of whom 611 (2.5%) developed cardiovascular complications. In total, 458 (1.9%) patients died within 30 days of surgery, of which 123 (26.9%) deaths were judged to be cardiac-related. Mortality rates were higher in patients who developed postoperative cardiovascular complications than in those who did not (19.8% vs. 1.4%), which persisted after risk adjustment (hazard ratio (95%CI) 4.15 (3.14-5.48)). We estimated an absolute risk reduction (95%CI) of 0.4 (0.3-0.5) in mortality in the absence of all cardiovascular complications. This would confer a relative risk reduction in mortality of 21.1% if all cardiovascular complications were prevented. Postoperative cardiovascular complications are relatively common and occur early after major abdominal surgery. However, over 1 in 5 postoperative deaths were attributable to these complications, highlighting an important area for future randomised trials.
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19
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Ali S, Roubos S, Hoeks SE, Verbrugge SJC, Koopman-van Gemert AWMM, Stolker RJ, van Lier F. Perioperative transfusion study (PETS): Does a liberal transfusion protocol improve outcome in high-risk cardiovascular patients undergoing non-cardiac surgery? A randomised controlled pilot study. Transfus Med 2024. [PMID: 38890740 DOI: 10.1111/tme.13058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/07/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Small studies have shown that patients with advanced coronary artery disease might benefit from a more liberal blood transfusion strategy. The goal of this pilot study was to test the feasibility of a blood transfusion intervention in a group of vascular surgery patients who have elevated cardiac troponins in rest. METHODS We conducted a single-centre, randomised controlled pilot study. Patients with a preoperative elevated high-sensitive troponin T undergoing non-cardiac vascular surgery were randomised between a liberal transfusion regime (haemoglobin >10.4 g/dL) and a restrictive transfusion regime (haemoglobin 8.0-9.6 g/dL) during the first 3 days after surgery. The primary outcome was defined as a composite endpoint of all-cause mortality, myocardial infarction or unscheduled coronary revascularization. RESULTS In total 499 patients were screened; 92 were included and 50 patients were randomised. Postoperative haemoglobin was different between the intervention and control group; 10.6 versus 9.8, 10.4 versus 9.4, 10.9 versus 9.4 g/dL on day one, two and three respectively (p < 0.05). The primary outcome occurred in four patients (16%) in the liberal transfusion group and in two patients (8%) in control group. CONCLUSION This pilot study shows that the studied transfusion protocol was able to create a clinically significant difference in perioperative haemoglobin levels. Randomisation was possible in 10% of the screened patients. A large definitive trial should be possible to provide evidence whether a liberal transfusion strategy could decrease the incidence of postoperative myocardial infarction in high risk surgical patients.
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Affiliation(s)
- Samir Ali
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Steven Roubos
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Sanne E Hoeks
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Serge J C Verbrugge
- Department of Anaesthesiology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | - Robert Jan Stolker
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Felix van Lier
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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20
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Wang K, Zheng K, Liu Q, Mo S, Guo S, Cao Y, Wu J, Wang S. Early postoperative acetylsalicylic acid administration does not increase the risk of postoperative intracranial bleeding in patients with spontaneous intracerebral hemorrhage. Neurosurg Rev 2024; 47:258. [PMID: 38839660 DOI: 10.1007/s10143-024-02481-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 04/17/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
Administration of acetylsalicylic acid (ASA) at early stage after surgery for spontaneous intracerebral hemorrhage (SICH) may increase the risk of postoperative intracranial bleeding (PIB), because of potential inhibition of platelet function. This study aimed to investigate whether early ASA administration after surgery was related to increased risk of PIB. This retrospective study enrolled SICH patients receiving surgery from September 2019 to December 2022 in seven medical institution. Based on postoperative ASA administration, patients who continuously received ASA more than three days within seven days post-surgery were identified as ASA users, otherwise as non-ASA users. The primary outcome was symptomatic PIB events within seven days after surgery. Incidence of PIB was compared between ASA users and non-ASA users using survival analysis. This study included 744 appropriate patients from 794 SICH patients. PIB occurred in 42 patients. Survival analysis showed no statistical difference between ASA users and non-ASA users in incidence of PIB (P = 0.900). Multivariate Cox analysis demonstrated current smoker (hazard ratio [HR], 2.50, 95%CI, 1.33-4.71, P = 0.005), dyslipidemia (HR = 3.03; 95%CI, 1.31-6.99; P = 0.010) and pre-hemorrhagic antiplatelet therapy (HR = 3.05; 95% CI, 1.64-5.68; P < 0.001) were associated with PIB. Subgroup analysis manifested no significant difference in incidence of PIB between ASA users and non-ASA users after controlling the effect from factors of PIB (i.e., sex, age, current smoker, regular drinker, dyslipidemia, pre-hemorrhagic antiplatelet therapy and hematoma location). This study revealed that early ASA administration to SICH patients after surgery was not related to increased risk of PIB.
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Affiliation(s)
- Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Kaige Zheng
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Shuaiwei Guo
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, 100070, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan hospital, Capital Medical University, Beijing, 100070, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China.
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21
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Konovalov A, Grebenev F, Artemyev A, Gadzhiagaev V, Pilipenko Y, Okishev D, Manushkova A, Eliava S, Chaurasia B. Haemorrhagic Complications After Microsurgical Treatment for Intracranial Aneurysms Under Acetylsalicylic Acid: An Impact Analysis. Cureus 2024; 16:e62622. [PMID: 39027790 PMCID: PMC11257376 DOI: 10.7759/cureus.62622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Patients with intracranial aneurysms often have comorbidities that require them to take acetylsalicylic acid (ASA). In recent years, many patients with aneurysms have been prescribed ASA to prevent aneurysm enlargement. ASA is also prescribed to patients with intracranial aneurysms in preparation for surgical revascularization. METHODS From 2016 to 2021, 64 patients underwent microsurgical aneurysm clipping without revascularization, and an additional 20 patients underwent extracranial to intracranial (EC-IC) bypass. The following parameters were analysed: the frequency of hemorrhagic complications, the blood loss volume, the duration of surgery and inpatient treatment, the change in hemoglobin level (Hb), hematocrit (Ht), erythrocytes, and clinical outcomes according to the modified Rankin scale (mRS). RESULTS At the time of surgery, laboratory-confirmed effect of the ASA was registered in 22 patients (main group). In 42 patients, the ASA was not functional on assay (control group). Hemorrhagic complications were noted in two patients in the ASA group. In both cases, the hemorrhagic component did not exceed 15 ml in volume and did not require additional surgical interventions. Statistical analysis showed no significant differences in hemorrhagic postoperative complications. CONCLUSION Taking low doses of acetylsalicylic acid during planned microsurgical clipping of cerebral aneurysms does not affect intraoperative blood loss volume, risk of postoperative hemorrhagic complications, length of stay in the hospital, or functional outcomes.
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Affiliation(s)
- Anton Konovalov
- Cerebrovascular Surgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Fyodor Grebenev
- Neurosurgery, Burdenko National Medical Scientific Research Centre of Neurosurgery, Moscow, RUS
| | - Anton Artemyev
- Neurosurgery, Educational Institution of Higher Education Sechenov First Moscow State Medical University, Moscow, RUS
| | - Vadim Gadzhiagaev
- Neurosurgery, M.F. Vladimirsky Moscow Regional Scientific Research Clinical Institute, Moscow, RUS
| | - Yuri Pilipenko
- Neurosurgery, Burdenko National Medical Scientific Research Centre of Neurosurgery, Moscow, RUS
| | - Dmitry Okishev
- Vascular Surgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Alina Manushkova
- Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Shalva Eliava
- Vascular Surgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Bipin Chaurasia
- Neurosurgery, Bhawani Hospital and Research Centre, Birgunj, NPL
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22
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Fan G, Lai H, Wang X, Feng Y, Cao Z, Qiu Y, Wen S. Development and external validation of a perioperative clinical model for predicting myocardial injury after major abdominal surgery: A retrospective cohort study. Heliyon 2024; 10:e30940. [PMID: 38799735 PMCID: PMC11126854 DOI: 10.1016/j.heliyon.2024.e30940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024] Open
Abstract
Purpose We aimed to develop and validate a predictive model for myocardial injury in individuals undergoing major abdominal surgery. Methods This multicenter retrospective cohort analysis included 3546 patients aged ≥45 years who underwent major abdominal surgeries at two Chinese tertiary hospitals. The primary outcome was myocardial injury after noncardiac surgery (MINS), defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The LASSO algorithm and logistic regression were used to construct a predictive model for postoperative MINS in the development cohort, and the performance of this prediction model was validated in an external independent cohort. Results A total of 3546 patients were included in our study. MINS manifested in 338 (9.53 %) patients after surgery. The definitive predictive model for MINS was developed by incorporating age, American Society of Anesthesiologists (ASA) classification, preoperative hemoglobin concentration, preoperative serum ALB concentration, blood loss, total infusion volume, and operation time. The area under the curve (AUC) of our model was 0.838 and 0.821 in the derivation and validation cohorts, respectively. Conclusions Preoperative hemoglobin levels, preoperative serum ALB concentrations, infusion volume, and blood loss are independent predictors of MINS. Our predictive model can prove valuable in identifying patients at moderate-to-high risk prior to non-cardiac surgery.
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Affiliation(s)
- Guifen Fan
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hanjin Lai
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiwen Wang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yulu Feng
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhongming Cao
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Yuxin Qiu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shihong Wen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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23
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Zöllner C. [Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]. DIE ANAESTHESIOLOGIE 2024; 73:294-323. [PMID: 38700730 PMCID: PMC11076399 DOI: 10.1007/s00101-024-01408-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Abstract
The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.
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Affiliation(s)
- Christian Zöllner
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Martinistr. 52, 20246, Hamburg, Deutschland.
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24
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Kulikov A, Konovalov A, Pugnaloni PP, Bilotta F. Aspirin interruption before neurosurgical interventions: A controversial problem. World J Cardiol 2024; 16:191-198. [PMID: 38690214 PMCID: PMC11056878 DOI: 10.4330/wjc.v16.i4.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/26/2024] [Accepted: 02/29/2024] [Indexed: 04/23/2024] Open
Abstract
Aspirin is widely used for primary or secondary prevention of ischemic events. At the same time, chronic aspirin consumption can affect blood clot formation during surgical intervention and increase intraoperative blood loss. This is especially important for high-risk surgery, including neurosurgery. Current European Society of Cardiology guidelines recommend aspirin interruption for at least 7 d before neurosurgical intervention, but this suggestion is not supported by clinical evidence. This narrative review presents evidence that challenges the necessity for aspirin interruption in neurosurgical patients, describes options for aspirin effect monitoring and the clinical implication of these methods, and summarizes current clinical data on bleeding risk associated with chronic aspirin therapy in neurosurgical patients, including brain tumor surgery, cerebrovascular procedures, and spinal surgery.
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Affiliation(s)
- Alexander Kulikov
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow 125047, Russia
| | - Anton Konovalov
- Department of Vascular Neurosurgery, Burdenko National Medical Research Center of Neurosurgery, Moscow 125047, Russia
| | - Pier Paolo Pugnaloni
- Department of Anesthesiology, Critical Care and Pain Medicine, University of Rome "Sapienza", Rome 00161, Italy
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, University of Rome "Sapienza", Rome 00161, Italy.
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25
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Saini S, Thakker PU, Ritts R, O'Rourke TK, Hemal AK. Safety and complications of continuation of aspirin therapy in patients undergoing robot-assisted laparoscopic simple prostatectomy. J Robot Surg 2024; 18:181. [PMID: 38662167 PMCID: PMC11045638 DOI: 10.1007/s11701-024-01946-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/14/2024] [Indexed: 04/26/2024]
Abstract
To evaluate the safety and feasibility of continued perioperative aspirin at the time of robotic assisted simple prostatectomy (RASP). We performed a retrospective review of our IRB approved institutional database of patients who underwent RASP between 2013 and 2022. Comparative groups included patients taking aspirin in the perioperative period and those not taking aspirin pre-operatively. The primary outcome was any post-operative bleeding related complication using the modified Clavien-Dindo classification. Secondary outcomes included the identification of risk factors for increased blood loss in the entire study population, operative time, and blood transfusion requirement. 143 patients underwent RASP of which 55 (38.5%) patients continued perioperative aspirin therapy and 88 (61.5%) patients did not. Baseline demographics were similar between groups. Patients taking perioperative aspirin had a higher rate of hypertension (74.5% vs 58.0%, p = 0.04) and other cardiovascular disease (30.9% vs 11.4%, p = 0.007). Postoperative complications were similar between the groups (Clavien-Dindo ≥ 3; p = 0.43). Median blood loss (150 cc vs 150 cc, p = 0.38), percentage drop in hemoglobin (13.4 vs 13.2, p = 0.94) and blood transfusion rate (3.6 vs 1.1, p = 0.56) were also similar between groups. The median blood loss was 150 ml for the whole study population. On regression analysis, neither aspirin nor any other variable was associated with increased blood loss (> 150 ml). Aspirin can be safely continued perioperatively in patients undergoing RASP without any risk of bleeding related complications, blood loss, or increased transfusion rate.
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Affiliation(s)
- Sumit Saini
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, 140 Charlois Boulevard, Winston-Salem, NC, 27103, USA
| | - Parth U Thakker
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, 140 Charlois Boulevard, Winston-Salem, NC, 27103, USA.
| | - Rory Ritts
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, 140 Charlois Boulevard, Winston-Salem, NC, 27103, USA
| | - Timothy K O'Rourke
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, 140 Charlois Boulevard, Winston-Salem, NC, 27103, USA
| | - Ashok K Hemal
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, 140 Charlois Boulevard, Winston-Salem, NC, 27103, USA
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26
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Wang B, Su Y, Ma C, Xu L, Mao Q, Cheng W, Lu Q, Zhang Y, Wang R, Lu Y, He J, Chen S, Chen L, Li T, Gao L. Impact of perioperative low-molecular-weight heparin therapy on clinical events of elderly patients with prior coronary stents implanted > 12 months undergoing non-cardiac surgery: a randomized, placebo-controlled trial. BMC Med 2024; 22:171. [PMID: 38649992 PMCID: PMC11036782 DOI: 10.1186/s12916-024-03391-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Little is known about the safety and efficacy of discontinuing antiplatelet therapy via LMWH bridging therapy in elderly patients with coronary stents implanted for > 12 months undergoing non-cardiac surgery. This randomized trial was designed to compare the clinical benefits and risks of antiplatelet drug discontinuation via LMWH bridging therapy. METHODS Patients were randomized 1:1 to receive subcutaneous injections of either dalteparin sodium or placebo. The primary efficacy endpoint was cardiac or cerebrovascular events. The primary safety endpoint was major bleeding. RESULTS Among 2476 randomized patients, the variables (sex, age, body mass index, comorbidities, medications, and procedural characteristics) and percutaneous coronary intervention information were not significantly different between the bridging and non-bridging groups. During the follow-up period, the rate of the combined endpoint in the bridging group was significantly lower than in the non-bridging group (5.79% vs. 8.42%, p = 0.012). The incidence of myocardial injury in the bridging group was significantly lower than in the non-bridging group (3.14% vs. 5.19%, p = 0.011). Deep vein thrombosis occurred more frequently in the non-bridging group (1.21% vs. 0.4%, p = 0.024), and there was a trend toward a higher rate of pulmonary embolism (0.32% vs. 0.08%, p = 0.177). There was no significant difference between the groups in the rates of acute myocardial infarction (0.81% vs. 1.38%), cardiac death (0.24% vs. 0.41%), stroke (0.16% vs. 0.24%), or major bleeding (1.22% vs. 1.45%). Multivariable analysis showed that LMWH bridging, creatinine clearance < 30 mL/min, preoperative hemoglobin < 10 g/dL, and diabetes mellitus were independent predictors of ischemic events. LMWH bridging and a preoperative platelet count of < 70 × 109/L were independent predictors of minor bleeding events. CONCLUSIONS This study showed the safety and efficacy of perioperative LMWH bridging therapy in elderly patients with coronary stents implanted > 12 months undergoing non-cardiac surgery. An alternative approach might be the use of bridging therapy with half-dose LMWH. TRIAL REGISTRATION ISRCTN65203415.
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Affiliation(s)
- Bin Wang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yanhui Su
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Cong Ma
- Health Management Institute, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Lining Xu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qunxia Mao
- National Research Institute for Family Planning, Beijing, China
| | - Wenjia Cheng
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qingming Lu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Ying Zhang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Rong Wang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yan Lu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Jing He
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Shihao Chen
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Lei Chen
- Department of Thoracic Surgery of The First Medical Center, General Hospital of Chinese People's Liberation Army, Beijing, 100853, China.
| | - Tianzhi Li
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Linggen Gao
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China.
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27
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Fuchs C, Scheer CS, Wauschkuhn S, Vollmer M, Meissner K, Hahnenkamp K, Gründling M, Selleng S, Thiele T, Borgstedt R, Kuhn SO, Rehberg S, Scholz SS. Continuation of chronic antiplatelet therapy is not associated with increased need for transfusions: a cohort study in critically ill septic patients. BMC Anesthesiol 2024; 24:146. [PMID: 38627682 PMCID: PMC11022363 DOI: 10.1186/s12871-024-02516-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 03/28/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND The decision to maintain or halt antiplatelet medication in septic patients admitted to intensive care units presents a clinical dilemma. This is due to the necessity to balance the benefits of preventing thromboembolic incidents and leveraging anti-inflammatory properties against the increased risk of bleeding. METHODS This study involves a secondary analysis of data from a prospective cohort study focusing on patients diagnosed with severe sepsis or septic shock. We evaluated the outcomes of 203 patients, examining mortality rates and the requirement for transfusion. The cohort was divided into two groups: those whose antiplatelet therapy was sustained (n = 114) and those in whom it was discontinued (n = 89). To account for potential biases such as indication for antiplatelet therapy, propensity score matching was employed. RESULTS Therapy continuation did not significantly alter transfusion requirements (discontinued vs. continued in matched samples: red blood cell concentrates 51.7% vs. 68.3%, p = 0.09; platelet concentrates 21.7% vs. 18.3%, p = 0.82; fresh frozen plasma concentrates 38.3% vs. 33.3%, p = 0.7). 90-day survival was higher within the continued group (30.0% vs. 70.0%; p < 0.001) and the Log-rank test (7-day survivors; p = 0.001) as well as Cox regression (both matched samples) suggested an association between continuation of antiplatelet therapy < 7 days and survival (HR: 0.24, 95%-CI 0.10 to 0.63, p = 0.004). Sepsis severity expressed by the SOFA score did not differ significantly in matched and unmatched patients (both p > 0.05). CONCLUSIONS The findings suggest that continuing antiplatelet therapy in septic patients admitted to intensive care units could be associated with a significant survival benefit without substantially increasing the need for transfusion. These results highlight the importance of a nuanced approach to managing antiplatelet medication in the context of severe sepsis and septic shock.
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Affiliation(s)
- Christian Fuchs
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Christian S Scheer
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Steffi Wauschkuhn
- Department of Psychosomatic Medicine and Psychotherapy, Ernst von Bergmann Hospital, Potsdam, Germany
| | - Marcus Vollmer
- Institute of Bioinformatics, University Medicine Greifswald, Greifswald, Germany
| | - Konrad Meissner
- Department of Anaesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Klaus Hahnenkamp
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Matthias Gründling
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Sixten Selleng
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Rainer Borgstedt
- Department of Anaesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, Medical School, Protestant Hospital of the Bethel Foundation, Bielefeld University, University Medical Center OWL, Burgsteig 13, 33617, Bielefeld, Germany
| | - Sven-Olaf Kuhn
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Sebastian Rehberg
- Department of Anaesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, Medical School, Protestant Hospital of the Bethel Foundation, Bielefeld University, University Medical Center OWL, Burgsteig 13, 33617, Bielefeld, Germany
| | - Sean Selim Scholz
- Department of Anaesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, Medical School, Protestant Hospital of the Bethel Foundation, Bielefeld University, University Medical Center OWL, Burgsteig 13, 33617, Bielefeld, Germany.
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28
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Lavikainen LI, Guyatt GH, Luomaranta AL, Cartwright R, Kalliala IEJ, Couban RJ, Aaltonen RL, Aro KM, Cárdenas JL, Devereaux PJ, Galambosi PJ, Ge FZ, Halme ALE, Haukka J, Izett-Kay ML, Joronen KM, Karjalainen PK, Khamani N, Oksjoki SM, Pourjamal N, Singh T, Tähtinen RM, Vernooij RWM, Tikkinen KAO. Risk of thrombosis and bleeding in gynecologic cancer surgery: systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:403-416. [PMID: 37827272 DOI: 10.1016/j.ajog.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE This study aimed to provide procedure-specific estimates of the risk of symptomatic venous thromboembolism and major bleeding in the absence of thromboprophylaxis, following gynecologic cancer surgery. DATA SOURCES We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar for observational studies. We also reviewed reference lists of eligible studies and review articles. We performed separate searches for randomized trials addressing effects of thromboprophylaxis and conducted a web-based survey on thromboprophylaxis practice. STUDY ELIGIBILITY CRITERIA Observational studies enrolling ≥50 adult patients undergoing gynecologic cancer surgery procedures reporting absolute incidence for at least 1 of the following were included: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding requiring reintervention (including reexploration and angioembolization), bleeding leading to transfusion, or postoperative hemoglobin <70 g/L. METHODS Two reviewers independently assessed eligibility, performed data extraction, and evaluated risk of bias of eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors. The GRADE approach was applied to rate evidence certainty. RESULTS We included 188 studies (398,167 patients) reporting on 37 gynecologic cancer surgery procedures. The evidence certainty was generally low to very low. Median symptomatic venous thromboembolism risk (in the absence of prophylaxis) was <1% in 13 of 37 (35%) procedures, 1% to 2% in 11 of 37 (30%), and >2.0% in 13 of 37 (35%). The risks of venous thromboembolism varied from 0.1% in low venous thromboembolism risk patients undergoing cervical conization to 33.5% in high venous thromboembolism risk patients undergoing pelvic exenteration. Estimates of bleeding requiring reintervention varied from <0.1% to 1.3%. Median risks of bleeding requiring reintervention were <1% in 22 of 29 (76%) and 1% to 2% in 7 of 29 (24%) procedures. CONCLUSION Venous thromboembolism reduction with thromboprophylaxis likely outweighs the increase in bleeding requiring reintervention in many gynecologic cancer procedures (eg, open surgery for ovarian cancer and pelvic exenteration). In some procedures (eg, laparoscopic total hysterectomy without lymphadenectomy), thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding venous thromboembolism and bleeding.
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Affiliation(s)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Anna L Luomaranta
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Rufus Cartwright
- Department of Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom; Department of Epidemiology and Biostatistics, Imperial College London, London, United Kingdom
| | - Ilkka E J Kalliala
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Rachel J Couban
- Department of Anesthesia, McMaster University, Hamilton, Canada
| | - Riikka L Aaltonen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Karoliina M Aro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jovita L Cárdenas
- Direction of Health Technology Assessment, National Center for Health Technology Excellence (CENETEC), Mexico City, Mexico
| | - P J Devereaux
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada; Outcomes Research Consortium, Cleveland, OH
| | - Päivi J Galambosi
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fang Zhou Ge
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Alex L E Halme
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Haukka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Matthew L Izett-Kay
- Urogynaecology Department, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Kirsi M Joronen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi K Karjalainen
- Department of Obstetrics and Gynecology, Central Finland Central Hospital, Jyväskylä, Finland; Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Nadina Khamani
- Department of Obstetrics and Gynecology, Institute of Children's Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Negar Pourjamal
- Laboratory of Molecular Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tino Singh
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Riikka M Tähtinen
- Department of Obstetrics and Gynecology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Robin W M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kari A O Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Surgery, South Karelia Central Hospital, Lappeenranta, Finland.
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Falck-Jones R, Bell M, Hallqvist L. Incidence and risk factors of peri-operative stroke in major non-cardiovascular, non-neurologic surgery-A retrospective register-based cohort study. Acta Anaesthesiol Scand 2024; 68:485-492. [PMID: 38212290 DOI: 10.1111/aas.14373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/24/2023] [Accepted: 12/29/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Peri-operative stroke is a rare but serious surgical complication. Both overt and covert stroke, occurring in approximately 0.1% and 7% of cases, respectively, are associated with significant long-term effects and increased morbidity. METHODS Retrospective register data for patients >18 years old, presenting for major non-cardiovascular, non-neurosurgical and non-ambulatory surgical procedures at 23 hospitals in Sweden between 2007 and 2014 was collected and linked with various quality registers. The primary outcome was stroke within 30 days from surgery. Using multivariable logistic regression, significant independent risk factors influencing the primary outcome were identified and their adjusted odds ratios (ORs) were calculated. Mortality was assessed, along with the composite score of days alive and at home within 30 days after surgery (DAH 30). RESULTS In total, 318,017 patients were included, with 687 (0.22%) suffering a stroke within 30 days of surgery. The strongest significant risk factors included: increasing ASA-class (OR [95% confidence interval, CI]: 2.23 [1.53-3.36], 3.91 [2.68-5.93] and 7.82 [5.03-12.5] for ASA 2, 3 and 4, respectively) and age (OR [95% CI]: 4.47 [2.21-10.3], 9.9 [5.15-22.1], 16.3 [8.48-36.5] and 21 [10.6-48.1], for age 45-59, 60-74, 75-89 and >90, respectively), along with non-elective procedures, male gender and a history of cerebrovascular disease (OR [95%]: 2.72 [2.25-3.27]). Mortality was increased and DAH 30 was reduced in patients suffering a stroke. CONCLUSIONS Increasing ASA-class and age was clearly associated with an increased risk of peri-operative stroke, which in turn was associated with increased mortality and poorer outcome. Detailed pre-operative risk stratification and individualised peri-operative management could potentially improve patient-centred outcomes and, in turn, have positive implications for public health.
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Affiliation(s)
- Ryan Falck-Jones
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Max Bell
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Linn Hallqvist
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
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Halme ALE, Roshanov PS, Tornberg SV, Lavikainen LI, Devereaux PJ, Tikkinen KAO. Timing of Major Postoperative Bleeding Among Patients Undergoing Surgery. JAMA Netw Open 2024; 7:e244581. [PMID: 38564217 PMCID: PMC10988355 DOI: 10.1001/jamanetworkopen.2024.4581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/31/2024] [Indexed: 04/04/2024] Open
Abstract
Importance Although major bleeding is among the most common and prognostically important perioperative complications, the relative timing of bleeding events is not well established. This information is critical for preventing bleeding complications and for informing the timing of pharmacologic thromboprophylaxis. Objective To determine the timing of postoperative bleeding among patients undergoing surgery for up to 30 days after surgery. Design, Setting, and Participants This is a secondary analysis of a prospective cohort study. Patients aged 45 years or older who underwent inpatient noncardiac surgery were recruited in 14 countries between 2007 and 2013, with follow-up until December 2014. Data analysis was performed from June to July 2023. Exposure Noncardiac surgery requiring overnight hospital admission. Main Outcomes and Measures The primary outcome (postoperative major bleeding) was a composite of the timing of the following bleeding outcomes: (1) bleeding leading to transfusion, (2) bleeding leading to a postoperative hemoglobin level less than 7 g/dL, (3) bleeding leading to death, and (4) bleeding associated with reintervention. Each of the components of the composite primary outcome (1-4) and bleeding independently associated with mortality after noncardiac surgery, which was defined as a composite of outcomes 1 to 3, were secondary outcomes. Results Among 39 813 patients (median [IQR] age, 63.0 [54.8-72.5] years; 19 793 women [49.7%]), there were 5340 major bleeding events (primary outcome) in 4638 patients (11.6%) within the first 30 days after surgery. Of these events, 42.7% (95% CI, 40.9%-44.6%) occurred within 24 hours after surgery, 77.7% (95% CI, 75.8%-79.5%) by postoperative day 7, 88.3% (95% CI, 86.5%-90.2%) by postoperative day 14, and 94.6% (95% CI, 92.7%-96.5%) by postoperative day 21. Within 48 hours of surgery, 56.2% of major bleeding events, 56.2% of bleeding leading to transfusion, 56.1% of bleeding independently associated with mortality after noncardiac surgery, 51.8% of bleeding associated with hemoglobin less than 7 g/dL, and 51.8% of bleeding associated with reintervention had occurred. Conclusions and Relevance In this cohort study, of the major postoperative bleeding events in the first 30 days, more than three-quarters occurred during the first postoperative week. These findings are useful for researchers for the planning future clinical research and for clinicians in prevention of bleeding-related surgical complications and in decision-making regarding starting of pharmacologic thromboprophylaxis after surgery.
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Affiliation(s)
| | - Pavel S. Roshanov
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Outcomes Research Consortium, Cleveland, Ohio
| | - Sara V. Tornberg
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - P. J. Devereaux
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Outcomes Research Consortium, Cleveland, Ohio
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kari A. O. Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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Kanstrup CTB, Svarre KJ, Rasmussen MC, Serup CM, Lundstrøm LH, Kleif J, Bertelsen CA. The effects of troponin screening among patients undergoing acute high-risk abdominal surgery: A retrospective cohort study. Acta Anaesthesiol Scand 2024; 68:476-484. [PMID: 38213306 DOI: 10.1111/aas.14371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/29/2023] [Accepted: 12/14/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Acute high-risk abdominal (AHA) surgery is associated with a high short-term mortality rate. This might be partly attributed to myocardial injury after non-cardiac surgery (MINS) defined by elevated postoperative troponin levels. The myocardial injury is often asymptomatic; thus, troponin screening seems to be the best diagnostic method. We aimed to assess whether implementing troponin screening with subsequent individualised interventions as standard care is associated with reduced mortality after AHA surgery. We also explored the treatment implications in the screening period. METHODS A retrospective cohort of 558 patients undergoing surgery from February 2018 to March 2021 was included. The patients undergoing surgery before March 2019 served as the historical control group, while the screening group consisted of patients undergoing surgery from March 1, 2019. Troponin I was to be measured 6-12 h postoperatively and in the morning of the succeeding 4 days. Patients with myocardial injury were assessed, and treatment was individualised after multiple disciplinary consultations. The primary outcome was the unadjusted 30-day mortality rates. Inverse probability treatment weighting was used to adjust for selection bias. RESULTS We included 558 patients: 382 in the screening group and 176 in the historical control group. In the screening group, 15 patients (3.9%) died before the first blood sampling, and in 31 patients (8.1%), troponin screening was omitted, leaving only 336 patients screened. Myocardial injury was diagnosed in 81 patients (24.1%) of the 336 patients. Of these, 59 (72.8%) had a cardiac consultation. No interventions or alterations in relation to myocardial injury were done in 67 patients (82.7%). The 30-day mortality was 13.8% (95% CI 8.7%-18.9%) in the control group and 11.1% (95% CI 8.0%-14.3%) in the screening group. The absolute risk difference was -2.7% (95% CI -8.7%-3.3%; p = .38), which was unchanged after adjustment. The difference remained unchanged after 90 days and 1 year. CONCLUSION The implementation of postoperative troponin screening was not associated with reduced mortality after AHA surgery. Research on the prevention and treatment of MINS is warranted before the implementation of standard troponin screening.
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Affiliation(s)
- Charlotte T B Kanstrup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Graduate School, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristina Johansen Svarre
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maja Christine Rasmussen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Camilla Mattesen Serup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Jakob Kleif
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Claus Anders Bertelsen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Arrigo M, Price S, Harjola VP, Huber LC, Schaubroeck HAI, Vieillard-Baron A, Mebazaa A, Masip J. Diagnosis and treatment of right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale): a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:304-312. [PMID: 38135288 PMCID: PMC10927027 DOI: 10.1093/ehjacc/zuad157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 12/24/2023]
Abstract
Acute right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale) is a life-threatening condition that may arise in different clinical settings. Patients at risk of developing or with manifest acute cor pulmonale usually present with an acute pulmonary disease (e.g. pulmonary embolism, pneumonia, and acute respiratory distress syndrome) and are managed initially in emergency departments and later in intensive care units. According to the clinical setting, other specialties are involved (cardiology, pneumology, internal medicine). As such, coordinated delivery of care is particularly challenging but, as shown during the COVID-19 pandemic, has a major impact on prognosis. A common framework for the management of acute cor pulmonale with inclusion of the perspectives of all involved disciplines is urgently needed.
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Affiliation(s)
- Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Birmensdorferstrasse 497, 8063 Zürich, Switzerland
| | - Susanna Price
- Royal Brompton Hospital, National Heart & Lung Institute, Imperial College London, London, UK
| | - Veli-Pekka Harjola
- Department of Emergency Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Lars C Huber
- Department of Internal Medicine, Stadtspital Zurich, Birmensdorferstrasse 497, 8063 Zürich, Switzerland
| | | | | | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care Medicine, AP-HP, Hôpitaux Universitaires Saint-Louis-Lariboisière, FHU PROMICE, INI-CRCT, and Université de Paris, MASCOT, Inserm, Paris, France
| | - Josep Masip
- Research Direction, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain
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Han HJ, Kim J, Jang CK, Kim JJ, Park KY, Park SK, Chung J, Kim YB. Perioperative Low-Dose Aspirin Management for Planned Clipping Surgery: When, How Long, and With What Precautions? Neurosurgery 2024; 94:597-605. [PMID: 37800926 DOI: 10.1227/neu.0000000000002710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/10/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Perioperative low-dose aspirin (ASA) management for open craniotomy surgery lacked information. We analyze to establish the perioperative ASA strategy to minimize both hemorrhagic and thromboembolic complications. METHODS The investigators designed a multicenter retrospective study, which included patients scheduled to have clipping surgery for unruptured intracranial aneurysm. The incidence and risk factors were analyzed for postoperative hemorrhagic complications and major cardio- and cerebrovascular events (MACCEs) within 1 month postoperation. RESULTS This study included 503 long-term ASA users of 3654 patients at three tertiary centers. The incidence of hemorrhagic complications and MACCEs was 7.4% (37/503) and 8.8% (44/503), respectively. Older age (>70 years, odds ratio [OR]: 2.928, 95% CI [1.337-6.416]), multiple aneurysms operation (OR: 2.201, 95% CI [1.017-4.765]), large aneurysm (>10 mm, OR: 4.483, 95% CI [1.485-13.533]), and ASA continuation (OR: 2.604, 95% CI [1.222-5.545]) were independent risk factors for postoperative hemorrhagic complications. Intracranial hemorrhage was the only type of hemorrhagic complication that increased in the ASA continuation group (10.6% vs 2.9%, P = .001). Between the ASA continuation and discontinuation groups, the overall incidence of MACCEs was not significantly different (log-rank P = .8). In the subgroup analysis, ASA discontinuation significantly increased the risk of MACCEs in the secondary prevention group (adjusted hazard ratio: 2.580, 95% CI [1.015-6.580]). CONCLUSION ASA continuation increased the risk of postoperative intracranial hemorrhage. Simultaneously, ASA discontinuation was the major risk factor for postoperative MACCEs in the high-risk group. Without evidence of intracranial hemorrhage, early ASA resumption was indicated (a total cessation duration <7-10 days) in the secondary prevention group.
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Affiliation(s)
- Hyun Jin Han
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Junhyung Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Chang Ki Jang
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin , Gyeonggi-do , Republic of Korea
| | - Jung-Jae Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
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Zian A, Overdevest GM, Schutte PJ, Klok FA, Steyerberg EW, Moojen WA, van der Gaag NA. Aspin: neurosurgical aspirin intervention prognostic study - perioperative continuation versus discontinuation of aspirin in lumbar spinal surgery, a randomized controlled, noninferiority trial. Trials 2024; 25:156. [PMID: 38424535 PMCID: PMC10905870 DOI: 10.1186/s13063-024-07945-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
RATIONALE Aspirin is typically discontinued in cranial and spinal surgery because of the increased risk of hemorrhagic complications, but comes together with the risk of resulting in an increase of cardiac and neurologic thrombotic perioperative events. OBJECTIVE The aim of this study is to investigate the non-inferiority of perioperative continuation of aspirin patients undergoing low complex lumbar spinal surgery, compared with the current policy of perioperative discontinuation of aspirin. STUDY DESIGN A randomized controlled trial with two parallel groups of 277 cases (554 in total). STUDY POPULATION Patients undergoing low complex lumbar spinal surgery and using aspirin. All patients are aged >18 years. INTERVENTION Peri-operative continuation of aspirin. STUDY OUTCOMES Primary study outcome: composite of the following bleeding complications: Neurological deterioration as a result of hemorrhage in the surgical area with cauda and/or nerve root compression. Post-surgical anemia with hemoglobin level lower than 5 mmol/l, requiring transfusion. Subcutaneous hematoma leading to wound leakage and pain higher than NRS=7. Major and/or minor hemorrhage in any other body system according to the definition of the International Society on Thrombosis and Haemostasis bleeding scale. Secondary study outcomes: Each of the individual components of the primary outcome Absolute mean difference in operative blood loss between the study arms Thrombo-embolic-related complications: Myocardial infarction Venous thromboembolism Stroke Arterial thromboembolism FURTHER STUDY OUTCOMES: Anticoagulant treatment satisfaction by the Anti-Clot Treatment Scale (ACTS) and general health by the Patient-Reported Outcomes Measurement Information System (PROMIS Global-10) in the pre- and postoperative phase. NATURE AND EXTENT OF THE BURDEN AND RISKS ASSOCIATED WITH PARTICIPATION, BENEFIT, AND GROUP RELATEDNESS: Participation in this study imposes no additional risk to patients. Currently, there is no consensus on whether or not aspirin should be discontinued before cranial or spinal surgery. Currently, aspirin is typically discontinued in cranial and spinal surgery, because of a potential increased risk of hemorrhagic complication. An argument not based on a clinical trial. However, this policy might delay surgical procedures or carry the risk of resulting in an increase in cardiac and neurologic thrombotic perioperative events. It is unclear if the possibility of an increase in hemorrhage-related complications outweighs the risk of an increase in cardiac and neurologic thrombotic perioperative events. Furthermore, the Data Safety Monitoring Board (DSMB) will be asked for safety analysis by monitoring the study. There are no further disadvantages to participating in this study. Outcome measurements are recorded during admission and regular outpatient visits, and thus, do not require additional visits to the hospital.
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Affiliation(s)
- Ahmed Zian
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands.
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands.
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands.
| | - Gijsbert M Overdevest
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Pieter J Schutte
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Vascular Internal Medicine, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Ewout W Steyerberg
- Department of Clinical Biostatistics and Medical Decision Making, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Wouter A Moojen
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Niels A van der Gaag
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands
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Lavikainen LI, Guyatt GH, Sallinen VJ, Karanicolas PJ, Couban RJ, Singh T, Lee Y, Elberkennou J, Aaltonen R, Ahopelto K, Beilmann-Lehtonen I, Blanker MH, Cárdenas JL, Cartwright R, Craigie S, Devereaux P, Garcia-Perdomo HA, Ge FZ, Gomaa HA, Halme AL, Haukka J, Karjalainen PK, Kilpeläinen TP, Kivelä AJ, Lampela H, Mattila AK, Najafabadi BT, Nykänen TP, Pandanaboyana S, Pourjamal N, Ratnayake CB, Raudasoja A, Vernooij RW, Violette PD, Wang Y, Xiao Y, Yao L, Tikkinen KAO. Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery. Ann Surg 2024; 279:213-225. [PMID: 37551583 PMCID: PMC10782937 DOI: 10.1097/sla.0000000000006059] [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] [Indexed: 08/09/2023]
Abstract
OBJECTIVE To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding after abdominal surgery. BACKGROUND The use of pharmacological thromboprophylaxis represents a trade-off that depends on VTE and bleeding risks that vary between procedures; their magnitude remains uncertain. METHODS We identified observational studies reporting procedure-specific risks of symptomatic VTE or major bleeding after abdominal surgery, adjusted the reported estimates for thromboprophylaxis and length of follow-up, and estimated cumulative incidence at 4 weeks postsurgery, stratified by VTE risk groups, and rated evidence certainty. RESULTS After eligibility screening, 285 studies (8,048,635 patients) reporting on 40 general abdominal, 36 colorectal, 15 upper gastrointestinal, and 24 hepatopancreatobiliary surgery procedures proved eligible. Evidence certainty proved generally moderate or low for VTE and low or very low for bleeding requiring reintervention. The risk of VTE varied substantially among procedures: in general abdominal surgery from a median of <0.1% in laparoscopic cholecystectomy to a median of 3.7% in open small bowel resection, in colorectal from 0.3% in minimally invasive sigmoid colectomy to 10.0% in emergency open total proctocolectomy, and in upper gastrointestinal/hepatopancreatobiliary from 0.2% in laparoscopic sleeve gastrectomy to 6.8% in open distal pancreatectomy for cancer. CONCLUSIONS VTE thromboprophylaxis provides net benefit through VTE reduction with a small increase in bleeding in some procedures (eg, open colectomy and open pancreaticoduodenectomy), whereas the opposite is true in others (eg, laparoscopic cholecystectomy and elective groin hernia repairs). In many procedures, thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding VTE and bleeding.
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Affiliation(s)
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ville J. Sallinen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paul J. Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rachel J. Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Tino Singh
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Yung Lee
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Riikka Aaltonen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Kaisa Ahopelto
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ines Beilmann-Lehtonen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marco H. Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jovita L. Cárdenas
- Direction of Health Technologies Assessment, National Center for Health Technology Excellence (CENETEC), Mexico City, Mexico
| | - Rufus Cartwright
- Departments of Gynecology and Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Samantha Craigie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - P.J. Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Anesthesiology, Perioperative Medicine, and Surgical Research Group, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Outcomes Research, Outcomes Research Consortium, Cleveland, OH, USA
| | - Herney A. Garcia-Perdomo
- Department of Surgery, Division of Urology, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Fang Zhou Ge
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Huda A. Gomaa
- Department of Biostatistics, High Institute of Public Health, Alexandria University, Egypt
- Department of Medical Pharmacology, Tanta Chest Hospital, Ministry of Health and Population, Tanta, Egypt
| | - Alex L.E. Halme
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Haukka
- Health Sciences, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Päivi K. Karjalainen
- Department of Obstetrics and Gynecology, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Tuomas P. Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti J. Kivelä
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Lampela
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne K. Mattila
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Borna Tadayon Najafabadi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Sanjay Pandanaboyana
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Negar Pourjamal
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Chathura B.B. Ratnayake
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | | | - Robin W.M. Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Philippe D. Violette
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Yuting Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yingqi Xiao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Nursing and West China School of Nursing, West China Hospital and Sichuan University, Chengdu, China
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Kari A. O. Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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Kanstrup CTB, Serup CM, Svarre KJ, Rasmussen MC, Lundstrøm LH, Kleif J, Bertelsen CA. Association between troponin I levels and mortality among patients undergoing acute high-risk abdominal surgery-A cohort study. World J Surg 2024; 48:361-370. [PMID: 38284768 DOI: 10.1002/wjs.12035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/20/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Myocardial injury after noncardiac surgery (MINS) is associated with 30-day mortality in heterogeneous surgical populations but is barely described after acute high-risk abdominal surgery. The impact of dynamic changes has not previously been investigated. The objectives were to determine the incidence of MINS in this population, the association between mortality and MINS, and whether plasma troponin I (TnI) dynamics have any impact on mortality. METHODS A prospective cohort study of 341 patients undergoing acute high-risk gastrointestinal surgery was conducted. Plasma TnI was measured at the first four postoperative days. MINS was defined as any increased TnI level >59 ng/L. TnI dynamic required either two succeeding measurements of TnI >59 ng/L with a >20% increase/fall or one measurement of TnI >59 ng/L with a succeeding measurement of TnI <59 ng/L with a >50% decrease. Adjusted mortality rates were calculated using inverse probability of treatment weighting and competing risk analyses. RESULTS The incidence of MINS was 23.8% and dynamic TnI changes occurred in 15.6% of the patients. The unadjusted 30-day and 1-year mortality were 19.8% and 35.9% in patients with MINS, compared with 2.7% and 11.6%, respectively, in patients without MINS (p < 0.001). After adjusting, the differences remained significant. There was no difference in mortality between patients with or without dynamic changes in TnI level. CONCLUSION MINS occurred frequently and was associated with increased mortality. TnI monitoring might help identify patients with increased risk of mortality and improve care. Research on preventive measures and treatments is warranted. TRIAL REGISTRATION NUMBER AND AGENCY ClinicalTrials.gov Identifier: NCT05933837, retrospective registered.
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Affiliation(s)
- Charlotte Tiffanie Bendtz Kanstrup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Graduate School, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Camilla Mattesen Serup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristina Johansen Svarre
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maja Christine Rasmussen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Jakob Kleif
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Claus Anders Bertelsen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Anusic N, Sessler DI. Innovative designs for trials informing the care of cardiac surgical patients: Part II. Curr Opin Anaesthesiol 2024; 37:49-54. [PMID: 38085856 DOI: 10.1097/aco.0000000000001334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW This review examines advances in clinical trial methodologies relevant to cardiac anesthesia. It focuses on innovative approaches, including factorial randomization, composite outcomes, and cluster randomized trials, which enhance the efficiency, practical relevance, and generalizability of trial outcomes. RECENT FINDINGS Factorial randomization is becoming popular because the approach allows investigators to simultaneously evaluate two or more interventions. Furthermore, factorial designs can evaluate interactions among treatments which is highly relevant information that cannot be obtained from separate trials. Composite outcomes are also increasingly utilized, combining multiple individual outcomes into a single measure, which increases statistical power and can better represent relevant physiology. Designing valid composites requires careful consideration of component outcome severity and incidence. Cluster randomized trials, including stepped wedge and multiple crossover designs, address the challenges of group-level effects and shared environments. SUMMARY The evolution of clinical trial designs is marked by a shift towards methodologies that enhance efficiency and provide more nuanced insights into treatment effects. These include factorial designs for simultaneous intervention assessment, composite outcomes for comprehensive physiological representation, and cluster trials for group-level effect analysis. Such advancements are shaping the future of clinical research, making it more relevant, efficient, and broadly applicable.
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Affiliation(s)
- Nikola Anusic
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
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Smilowitz NR. The impact of preoperative stress testing on cardiovascular and surgical care - Does it actually improve outcomes? J Clin Anesth 2024; 92:111267. [PMID: 37758564 DOI: 10.1016/j.jclinane.2023.111267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023]
Affiliation(s)
- Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, New York, NY, USA.
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Wang C, Lebedeva V, Yang J, Anih J, Park LJ, Paczkowski F, Roshanov PS. Desmopressin to reduce periprocedural bleeding and transfusion: a systematic review and meta-analysis. Perioper Med (Lond) 2024; 13:5. [PMID: 38263259 PMCID: PMC10804695 DOI: 10.1186/s13741-023-00358-4] [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: 10/18/2023] [Accepted: 12/29/2023] [Indexed: 01/25/2024] Open
Abstract
We systematically reviewed the literature to investigate the effects of peri-procedural desmopressin in patients without known inherited bleeding disorders undergoing surgery or other invasive procedures. We included 63 randomized trials (4163 participants) published up to February 1, 2023. Seven trials were published after a 2017 Cochrane systematic review on this topic. There were 38 trials in cardiac surgery, 22 in noncardiac surgery, and 3 in non-surgical procedures. Meta-analyses demonstrated that desmopressin likely does not reduce the risk of receiving a red blood cell transfusion (25 trials, risk ratio [RR] 0.95, 95% confidence interval [CI] 0.86 to 1.05) and may not reduce the risk of reoperation due to bleeding (22 trials, RR 0.75, 95% CI 0.47 to 1.19) when compared to placebo or usual care. However, we demonstrated significant reductions in number of units of red blood cells transfused (25 trials, mean difference -0.55 units, 95% CI - 0.94 to - 0.15), total volume of blood loss (33 trials, standardized mean difference - 0.40 standard deviations; 95% CI - 0.56 to - 0.23), and the risk of bleeding events (2 trials, RR 0.45, 95% CI 0.24 to 0.84). The certainty of evidence of these findings was generally low. Desmopressin increased the risk of clinically significant hypotension that required intervention (19 trials, RR 2.15, 95% CI 1.36 to 3.41). Limited evidence suggests that tranexamic acid is more effective than desmopressin in reducing transfusion risk (3 trials, RR 2.38 favoring tranexamic acid, 95% CI 1.06 to 5.39) and total volume of blood loss (3 trials, mean difference 391.7 mL favoring tranexamic acid, 95% CI - 93.3 to 876.7 mL). No trials directly informed the safety and hemostatic efficacy of desmopressin in advanced kidney disease. In conclusion, desmopressin likely reduces periprocedural blood loss and the number of units of blood transfused in small trials with methodologic limitations. However, the risk of hypotension needs to be mitigated. Large trials should evaluate desmopressin alongside tranexamic acid and enroll patients with advanced kidney disease.
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Affiliation(s)
- Carol Wang
- Department of Medicine, Western University, London, ON, Canada
| | | | - Jeffy Yang
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | - Lily J Park
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Freeman Paczkowski
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Pavel S Roshanov
- Department of Medicine, Western University, London, ON, Canada.
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
- Population Health Research Institute, Hamilton, ON, Canada.
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40
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Fanning JP, Campbell BCV, Bulbulia R, Gottesman RF, Ko SB, Floyd TF, Messé SR. Perioperative stroke. Nat Rev Dis Primers 2024; 10:3. [PMID: 38238382 DOI: 10.1038/s41572-023-00487-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/23/2024]
Abstract
Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- The George Institute for Global Health, Sydney, New South Wales, Australia.
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Sang-Bae Ko
- Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Thomas F Floyd
- Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Balakrishna A, Walco J, Billings FT, Lopez MG. Perioperative Acute Kidney Injury: Implications, Approach, Prevention. Adv Anesth 2023; 41:205-224. [PMID: 38251619 PMCID: PMC11079993 DOI: 10.1016/j.aan.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Acute kidney injury remains a common and significant contributor to perioperative morbidity. Acute kidney injury worsens patient outcomes, and anesthesiologists should make significant efforts to prevent, assess, and treat perioperative renal injury. The authors discuss the impact of renal injury on patient outcomes and putative underlying mechanisms, evidence underlying treatments for acute kidney injury, and practices that may prevent the development of perioperative renal injury.
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Affiliation(s)
- Aditi Balakrishna
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeremy Walco
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frederic T Billings
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marcos G Lopez
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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42
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Thilagar BP, Mueller MR, Ganesh R. Perioperative cardiac risk reduction in non cardiac surgery. Minerva Med 2023; 114:861-877. [PMID: 37140483 DOI: 10.23736/s0026-4806.23.08474-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
For patients undergoing nonemergent noncardiac surgery, care must be taken to identify patients at increased risk of major adverse cardiovascular events, as these remain a significant source of perioperative morbidity and mortality. Identification of at-risk patients requires careful attention to risk factors including assessment of functional status, medical comorbidities, and a medication assessment. After identification, to minimize perioperative cardiac risk, care should be taken through a combination of appropriate medication management, close monitoring for cardiovascular ischemic events, and optimization of pre-existing medical conditions. There are multiple society guidelines that aim to mitigate risk of cardiovascular morbidity and mortality in patients undergoing nonemergent noncardiac surgery. However, the rapid evolution of medical literature often creates gaps between the existing evidence and best practice recommendations. In this review, we aim to reconcile the recommendations made in the guidelines from the major cardiovascular and anesthesiology societies from the USA, Canada, and Europe, and to provide updated recommendations based on new evidence.
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Affiliation(s)
- Bright P Thilagar
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael R Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA -
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Koelker M, Bradtke M, Klemm J, von Deimling M, Gild P, Dahlem R, Fisch M, Rink M, Vetterlein MW. Rational peri-operative management of antithrombotic therapy in patients undergoing radical cystectomy: A 30-day morbidity analysis based on the updated European Association of Urology guidelines for standardized complication reporting. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107123. [PMID: 37879160 DOI: 10.1016/j.ejso.2023.107123] [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: 07/12/2023] [Revised: 10/14/2023] [Accepted: 10/20/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Radical cystectomy (RC) in bladder cancer patients with cardiovascular comorbidity poses challenges due to the need for antithrombotic therapy and high perioperative risk. We aimed to assess 30-day complications after RC in patients receiving antithrombotic therapy. PATIENTS AND METHODS Retrospective study of 416 bladder cancer patients (2009-2017) undergoing open RC with pelvic lymph node dissection, with or without antithrombotic therapy. Antithrombotic therapy and complication reporting followed European guidelines. Procedure-specific 30-day complications were cataloged, graded (Clavien-Dindo), and quantified using the 30-day Comprehensive Complication Index. Multivariable regressions evaluated antithrombotic therapy's independent effect on key morbidity outcomes. RESULTS Median age was 70 years, 78% were male. Patients on antithrombotic therapy were mostly male, had higher comorbidity burden, worse kidney function, more frequent incontinent diversion, and shorter operative time (all p ≤ 0.027). Bleeding complications occurred in 135 patients (32%; 95%CI = 28-37%), more prevalent with antithrombotic therapy (46% vs. 29%; p = 0.004). Thromboembolic complications occurred in 18 patients (4.3%; 95%CI = 2.6-6.8%), no difference between patients with and without antithrombotic therapy (8.4% vs. 3.3%; p = 0.063). Prevalence of myocardial infarction, new-onset hypertension, acute congestive heart failure, and angina pectoris showed no difference (all p ≥ 0.3). Multivariable analyses indicated no association between antithrombotic therapy and cardiac complications, 30-day major complications, or cumulative morbidity (all p ≥ 0.2). Antithrombotic therapy was associated with bleeding complications (OR = 1.92; 95%CI = 1.07-3.45; p = 0.028), predominantly transfusion-related (75% of 152 bleeding complications). Limitations include retrospective data assessment with biases. CONCLUSIONS RC in patients on antithrombotic therapy exhibits a higher incidence of adverse events due to underlying comorbidities. Adherence to thromboprophylaxis guidelines enables safe RC in patients with significant comorbidities, without substantial increase in major bleeding or severe thromboembolic events.
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Affiliation(s)
- Mara Koelker
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlon Bradtke
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Klemm
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus von Deimling
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Gild
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Katholisches Marienkrankenhaus, Hamburg, Germany
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Mao X, Liang C, Li X, Shi D, Yang Q, Xie H, Liang F, Cui Y. The impact of long-term aspirin use on the patients undergoing shoulder arthroplasty. J Orthop Surg Res 2023; 18:894. [PMID: 37993872 PMCID: PMC10666390 DOI: 10.1186/s13018-023-04374-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Although aspirin is increasingly utilized to reduce the event of severe perioperative complications, the effect of long-term aspirin use (L-AU) on perioperative complications in patients undergoing shoulder arthroplasty (SA) has not been well studied. The goal of the present study is to identify the influence of L-AU on perioperative complications in individuals undergoing SA. METHODS We selected data from the National Inpatient Sample database between 2010 and 2019, to identify adult patients with SA. Patients were subsequently categorized into L-AU and whole non-L-AU cohorts according to the presence of aspirin use. The demographic and comorbidity characteristics were matched using propensity score matching (PSM). The Pearson chi-square test, Wilcoxon rank test and logistic regression were utilized to assess the association of L-AU with perioperative complications. RESULTS From 2010 to 2019, a total of 162,418 SA patients satisfied the inclusion criteria, with 22,659 (13.95%) using aspirin on a long-term basis. The vast majority of the patients with pre-existing L-AU were aged 65-74 years, female, White and had Medicare insurance. L-AU before surgery was linked to increased risks of perioperative complications, such as blood transfusion (adjusted odds ratio [aOR]: 1.339), genitourinary disease (aOR: 1.349), acute renal failure (aOR: 1.292), acute myocardial infarction (aOR: 1.494), higher total charge (L-AU vs. the whole non-L-AU vs. matched non-L-AU: $66,727.15 vs. $59,697.08 vs. $59,926.32), and prolonged hospitalization stay (LOS) (aOR: 0.837). However, L-AU was considered a protective factor of acute cerebrovascular disease (aOR: 0.722) and stroke (aOR: 0.725). CONCLUSIONS Our study is based on the largest open-access all-payer inpatient database, revealing a noteworthy finding of aspirin's protective and adverse impact on different postoperative complications in the US population, such as acute cardiovascular disease, and stroke, etc. Further studies assessing the optimum preoperative aspirin duration and dosage to meet the best benefit quantity for patients with planned joint arthroplasties are suggested.
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Affiliation(s)
- Xiuhua Mao
- School of Health, Dongguan Polytechnic, Dongguan, 523000, Guangdong, China
| | - Chen Liang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Xiaoqin Li
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Danping Shi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Qinfeng Yang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Hao Xie
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China.
| | - Fangguo Liang
- Department of Plastic and Cosmetic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China.
| | - Yuhui Cui
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China.
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Hu Z, Li W, Zhao G, Liang C, Li K. Postoperative stellate ganglion block to reduce myocardial injury after laparoscopic radical resection for colorectal cancer: protocol for a randomised trial. BMJ Open 2023; 13:e069183. [PMID: 37977873 PMCID: PMC10660892 DOI: 10.1136/bmjopen-2022-069183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/31/2023] [Indexed: 11/19/2023] Open
Abstract
INTRODUCTION Stellate ganglion block (SGB) is usually used in the department of algiatry. But preoperative SGB may reduce adverse cardiovascular events in high-risk patients, although evidence remains sparse. Therefore, we aim to determine whether a single-shot postoperative SGB can reduce the incidence of myocardial injury after non-cardiac surgery (MINS) and improve recovery in patients undergoing laparoscopic radical resection for colorectal cancer. METHODS AND ANALYSIS This is an investigator-initiated, single-centre, randomised, two-arm clinical trial enrolling patients aged over 45 years and scheduled for elective laparoscopic radical colorectal surgery with at least one risk factor for MINS. A total of 950 eligible patients will be randomised into a routine or block groups. The primary outcome is the incidence of MINS. The secondary outcomes include the Visual Analogue Scale of pain during rest and movement, the incidence of delirium, quality of recovery (QOR) assessed by QOR-15, and sleep quality assessed by Richards Campbell Sleep Questionnaire. Tertiary outcomes include time to first flatus, gastrointestinal complications such as anastomotic leak or ileus, length of hospital stay, collapse incidence of severe cardiovascular and cerebrovascular complications of myocardial infarction, cardiac arrest, ischaemic or haemorrhagic stroke, and all-cause mortality within 30 days after the operation. ETHICS AND DISSEMINATION The protocol was approved by Medical Ethics Committee of the China-Japan Union Hospital, Jilin University (Approval number: 2021081018) prior to recruitment. The study will be performed according to the guidelines of the Declaration of Helsinki. The findings of this study will be published and presented through various scientific forums. TRIAL REGISTRATION NUMBER ChiCTR2200055319.
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Affiliation(s)
- Zhouting Hu
- Department of Anesthesiology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, People's Republic of China
| | - Wangyu Li
- Department of Pain Management, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, People's Republic of China
| | | | - Chen Liang
- New York University, New York, New York, USA
| | - Kai Li
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, People's Republic of China
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Lurati Buse G, Larmann J, Gillmann HJ, Kotfis K, Ganter MT, Bolliger D, Filipovic M, Guzzetti L, Chammartin F, Mauermann E, Ionescu D, Szczeklik W, De Hert S, Beck-Schimmer B, Howell SJ. NT-proBNP or Self-Reported Functional Capacity in Estimating Risk of Cardiovascular Events After Noncardiac Surgery. JAMA Netw Open 2023; 6:e2342527. [PMID: 37938844 PMCID: PMC10632953 DOI: 10.1001/jamanetworkopen.2023.42527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 09/13/2023] [Indexed: 11/10/2023] Open
Abstract
Importance Nearly 16 million surgical procedures are conducted in North America yearly, and postoperative cardiovascular events are frequent. Guidelines suggest functional capacity or B-type natriuretic peptides (BNP) to guide perioperative management. Data comparing the performance of these approaches are scarce. Objective To compare the addition of either N-terminal pro-BNP (NT-proBNP) or self-reported functional capacity to clinical scores to estimate the risk of major adverse cardiac events (MACE). Design, Setting, and Participants This cohort study included patients undergoing inpatient, elective, noncardiac surgery at 25 tertiary care hospitals in Europe between June 2017 and April 2020. Analysis was conducted in January 2023. Eligible patients were either aged 45 years or older with a Revised Cardiac Risk Index (RCRI) of 2 or higher or a National Surgical Quality Improvement Program, Risk Calculator for Myocardial Infarction and Cardiac (NSQIP MICA) above 1%, or they were aged 65 years or older and underwent intermediate or high-risk procedures. Exposures Preoperative NT-proBNP and the following self-reported measures of functional capacity were the exposures: (1) questionnaire-estimated metabolic equivalents (METs), (2) ability to climb 1 floor, and (3) level of regular physical activity. Main Outcome and Measures MACE was defined as a composite end point of in-hospital cardiovascular mortality, cardiac arrest, myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care. Results A total of 3731 eligible patients undergoing noncardiac surgery were analyzed; 3597 patients had complete data (1258 women [35.0%]; 1463 (40.7%) aged 75 years or older; 86 [2.4%] experienced a MACE). Discrimination of NT-proBNP or functional capacity measures added to clinical scores did not significantly differ (Area under the receiver operating curve: RCRI, age, and 4MET, 0.704; 95% CI, 0.646-0.763; RCRI, age, and 4MET plus floor climbing, 0.702; 95% CI, 0.645-0.760; RCRI, age, and 4MET plus physical activity, 0.724; 95% CI, 0.672-0.775; RCRI, age, and 4MET plus NT-proBNP, 0.736; 95% CI, 0.682-0.790). Benefit analysis favored NT-proBNP at a threshold of 5% or below, ie, if true positives were valued 20 times or more compared with false positives. The findings were similar for NSQIP MICA as baseline clinical scores. Conclusions and relevance In this cohort study of nearly 3600 patients with elevated cardiovascular risk undergoing noncardiac surgery, there was no conclusive evidence of a difference between a NT-proBNP-based and a self-reported functional capacity-based estimate of MACE risk. Trial Registration ClinicalTrials.gov Identifier: NCT03016936.
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Affiliation(s)
- Giovanna Lurati Buse
- Anesthesiology Department University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Jan Larmann
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hans-Jörg Gillmann
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Michael T. Ganter
- Department of Anesthesiology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Miodrag Filipovic
- Division of Anesthesiology, Intensive Care, Rescue and Pain Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Luca Guzzetti
- Anesthesia and Intensive Care Department, University Hospital, Varese, Italy
| | - Frédérique Chammartin
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Eckhard Mauermann
- Department of Anesthesiology, Zurich City Hospital, Zurich, Switzerland
| | - Daniela Ionescu
- Department of Anaesthesia and Intensive Care I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine Jagiellonian University Medical College, Kraków, Poland
| | - Stefan De Hert
- Department of Anaesthesiology and Peri-operative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Beatrice Beck-Schimmer
- Institute of Anaesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon J. Howell
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, United Kingdom
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Yang L, Shi S, Li J, Fang Z, Guo J, Kang W, Shi J, Yuan S, Yan F, Zhou C. Postoperative elevated cardiac troponin levels predict all-cause mortality and major adverse cardiovascular events following noncardiac surgery: A dose-response meta-analysis of prospective studies. J Clin Anesth 2023; 90:111229. [PMID: 37573706 DOI: 10.1016/j.jclinane.2023.111229] [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: 02/28/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
STUDY OBJECTIVE To perform a dose-response meta-analysis for the association between postoperative myocardial injury (PMI) in noncardiac surgery and the risk of all-cause mortality or major adverse cardiovascular event (MACE). DESIGN Dose-response meta-analysis of prospective studies with weighted (WL) or generalized (GL) linear and restricted cubic spline (RCS) regression. SETTING Teaching hospitals. PATIENTS Adult patients undergoing noncardiac surgery. INTERVENTIONS No. MEASUREMENTS The primary outcome was all-cause mortality. The secondary outcome was MACE. MAIN RESULTS 29 studies (53,518 patients) were included. The overall incidence of PMI was 26.0% (95% CI 21.0% to 32.0%). Compared to those without PMI, patients with PMI had an increased risk of all-cause mortality at short- (<12 months) (cardiac troponin[cTn]I: unadj OR 1.71,95%CI 1.22 to 2.41, P < 0.001; cTnT: unadj OR 2.33,95%CI 2.07 to 2.63, P < 0.001), and long-term (≥ 12 months) (cTnI: unadj OR 1.80, 95%CI 1.63 to 1.99; cTnT: unadj OR 1.47,95%CI 1.33 to 1.62) (All P < 0.001) follow-up. For MACE, the group with elevated values was associated with an increased risk (cTnI: unadj OR 1.98, 95% CI 1.13 to 3.47, P = 0.018; cTnT: unadj OR 2.29, 95% CI 1.88 to 2.79, P < 0.001). Dose-response analysis showed positive associations between PMI (per 1× upper reference limit[URL] increment) and all-cause mortality both at short- (unadj OR) (WL, OR 1.09, 95% CI 1.09 to 1.10; GL, OR 1.06, 95% CI 1.06 to 1.07; RCS in the range of 1-2× URL, OR = 2.43, 95%CI 2.25 to 2.62) and long-term follow-up (unadj HR) (WL, OR 1.16, 95% CI 1.14 to 1.17; GL, OR 1.15, 95% CI 1.13 to 1.16; RCS in the range of 1-2.75× URL, OR = 1.23, 95%CI 1.13 to 1.33), and MACE at longest follow-up (unadj OR) (WL: OR 1.53, 95% CI 1.49 to 1.57; GL: OR 1.46, 95% CI 1.42 to 1.50; RCS in the range of 1-2 x URL, OR = 3.10, 95%CI 2.51 to 3.81) (All P < 0.001). For mild cTn increase below URL, the risk of mortality increased with every increment of 0.25xURL (WL, OR 1.03, 95% CI 1.02 to 1.03; GL, OR 1.05, 95% CI 1.03 to 1.07; RCS in the range of 0-0.5 URL, OR = 9.41, 95% CI 7.41 to 11.95) (All P < 0.001). CONCLUSIONS This study shows positive WL or GL and RCS dose-response relationships between PMI and all-cause mortality at short (< 12 mons)- and long-term (≥ 12 mons) follow-up, and MACE at longest follow-up. For mild cTn increase below URL, the risk of mortality also increases even with every increment of 0.25× URL.
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Affiliation(s)
- Lijing Yang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Sheng Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jun Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Zhongrong Fang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jingfei Guo
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Wenying Kang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jia Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Fuxia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Chenghui Zhou
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China; Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.
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Sadri I, Chakraborty A, Nguyen DD, Arezki A, Oumedjbeur K, Bhojani N, Elterman D, Chughtai B, Gilling P, Barber N, Badlani G, Desai M, Doumanian L, Te AE, Roehrborn C, Zorn KC. Aquablation in Patients on Antithrombotics: Assessment of Safety, Postoperative Bleeding Rates and Clinical Outcomes. Urology 2023; 181:112-118. [PMID: 37574143 DOI: 10.1016/j.urology.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/01/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE To analyze the impact of perioperative antithrombotic use on the bleeding outcomes following Aquablation. METHODS One hundred sixteen men with who underwent Aquablation as part of the WATER prospective trial (NCT02505919) were assigned to 2 groups based on perioperative antithrombotic status. Antithrombotic cessation and restart timing were based on the surgeon's discretion. Methods of achieving intraoperative hemostasis consisted of no-cautery balloon tamponade or cautery. Primary endpoints included immediate postoperative hematuria rates and changes in hemoglobin. Secondary endpoints included 90-day bleeding complications and nonbleeding postoperative adverse events. RESULTS Forty-one men took antithrombotic medications in the perioperative period while 75 men had no antithrombotic medication. Preoperative hemoglobin levels were comparable between both groups. Postoperative hemoglobin change from baseline (drop of 1.8 ± 1.5 g/dL among the antithrombotic group vs 1.8 ± 1.7 g/dL among the antithrombotic-naïve group) did not differ between both groups (P = .896). In total, 4 (9.8%) men in the antithrombotic group and 4 (5.3%) patients in the antithrombotic-naïve group experienced a Clavien-Dindo grade 1 complication (P = .451) in the 3-month postoperative period. Eight (19.5%) patients in the antithrombotic group and 11 (14.7%) patients in the antithrombotic-naïve group experienced a Clavien-Dindo grade 2 complication (P = .601), none of which is associated with bleeding in both groups. No men in either group demonstrated de novo erectile dysfunction. One patient (2.4%) in the antithrombotic group and none in the antithrombotic-naïve group required blood products (P = .353). CONCLUSION Aquablation demonstrates comparable postoperative bleeding outcomes and other adverse effects for men with benign prostatic hypertrophy who are on antithrombotic therapy.
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Affiliation(s)
- Iman Sadri
- Department of Urology, McGill University, Montreal, Quebec, Canada
| | | | - David-Dan Nguyen
- Division of Urology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Adel Arezki
- Department of Urology, McGill University, Montreal, Quebec, Canada
| | - Kussil Oumedjbeur
- Division of Urology, Centre Hospitalier de L'Université de Montréal, Montreal, Quebec, Canada
| | - Naeem Bhojani
- Division of Urology, Centre Hospitalier de L'Université de Montréal, Montreal, Quebec, Canada
| | - Dean Elterman
- Division of Urology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bilal Chughtai
- Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY
| | - Peter Gilling
- Department of Urology, Tauranga Hospital, Tauranga, New Zealand
| | - Neil Barber
- Section of Urology, Department of Surgery, Frimley Health NHS Foundation Trust, Frimley, United Kingdom
| | - Gopal Badlani
- Department of Urology, Wake Forest University, Winston-Salem, NC
| | - Mihir Desai
- Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Leo Doumanian
- Institute of Urology, University of Southern California, Los Angeles, CA
| | - Alexis E Te
- Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY
| | - Claus Roehrborn
- Urology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Kevin C Zorn
- Division of Urology, Centre Hospitalier de L'Université de Montréal, Montreal, Quebec, Canada.
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49
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Duranteau O, Hamriti A, Ickx B, Tuna T. Influence of compliance to antithrombotic agents on perioperative morbidity and mortality. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:38. [PMID: 37853478 PMCID: PMC10583434 DOI: 10.1186/s44158-023-00123-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023]
Abstract
For patients on antithrombotic medication, the outcome of a planned surgery depends on the adjustment of their daily treatment. This study aimed to assess the impact of non-compliance to published recommendations about antithrombotic agents, specifically those provided by the Groupement d'Intérêt pour l'hémostase Peri-opératoire (GIHP), on patient morbidity and mortality.A prospective cohort observational monocentric study was conducted over a 7-month period in 2019 in an academic hospital. The study included patients on antithrombotic agents scheduled for elective surgery, excluding cardiac surgery. The primary endpoints were morbidity and mortality at 1 month according to GIHP guidelines compliance. Blood loss during surgery and length of hospital stay were secondary endpoints.Among the 589 patients included in the study, 87 complications were recorded, resulting in a morbidity rate of 14.8%. Thirty-six patients experienced hemorrhagic events, leading to 8 deaths, while 33 patients suffered from ischemic events, resulting in 3 deaths. Additionally, 18 patients died from causes unrelated to hemorrhage or ischemia. Compliance with GIHP guidelines was observed in 62% of patients. Statistical analysis did not reveal a significant association between adherence to guidelines and morbidity (p value = 0.923), nor between adherence and 1-month survival (p value = 0.698). Similarly, no statistically significant relationships were found between compliance and intraoperative bleeding volume (p value = 0.087), postoperative bleeding (p value = 0.460), or length of hospital stay (p value = 0.339).This study did not identify any substantial associations between non-strict adherence to GIHP recommendations and patient outcomes, including morbidity, mortality, and bleeding. However, it is important to interpret these findings with caution, considering the study's limitations and the need for further research in this area.
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Affiliation(s)
- Olivier Duranteau
- Anesthesiology Service, CUB-ULB Hôpital Erasme, Brussels, Belgium.
- Intensive Care Unit, HIA Percy, Clamart, France.
| | - Ayoub Hamriti
- Anesthesiology Service, CUB-ULB Hôpital Erasme, Brussels, Belgium
| | - Brigitte Ickx
- Anesthesiology Service, CUB-ULB Hôpital Erasme, Brussels, Belgium
| | - Turgay Tuna
- Anesthesiology Service, CUB-ULB Hôpital Erasme, Brussels, Belgium
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50
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Aparicio-López D, Asencio-Pascual JM, Blanco-Fernández G, Cugat-Andorrá E, Gómez-Bravo MÁ, López-Ben S, Martín-Pérez E, Sabater L, Ramia JM, Serradilla-Martín M. Evaluation of the validated intraoperative bleeding scale in liver surgery: study protocol for a multicenter prospective study. Front Surg 2023; 10:1223225. [PMID: 37850041 PMCID: PMC10577188 DOI: 10.3389/fsurg.2023.1223225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/18/2023] [Indexed: 10/19/2023] Open
Abstract
Background Surgical hemostasis has become one of the key principles in the advancement of surgery. Hemostatic agents are commonly administered in many surgical specialties, although the lack of consensus on the definition of intraoperative bleeding or of a standardized system for its classification means that often the most suitable agent is not selected. The recommendations of international organizations highlight the need for a bleeding severity scale, validated in clinical studies, that would allow the selection of the best hemostatic agent in each case. The primary objective of this study is to evaluate the VIBe scale (Validated Intraoperative Bleeding Scale) in humans. Secondary objectives are to evaluate the scale's usefulness in liver surgery; to determine the relationship between the extent of bleeding and the hemostatic agent used; and to assess the relationship between the grade of bleeding and postoperative complications. Methods Prospective multicenter observational study including 259 liver resections that meet the inclusion criteria: patients scheduled for liver surgery at one of 10 medium-high volume Spanish HPB centers using an open or minimally invasive approach (robotic/laparoscopic/hybrid), regardless of diagnosis, ASA score <4, age ≥18, and who provide signed informed consent during the study period (September 2023 until the required sample size has been recruited). The participating researchers will be responsible for collecting the data and for reporting them to the study coordinators. Discussion This study will allow us to evaluate the VIBe scale for intraoperative bleeding in humans, with a view to its subsequent incorporation in daily clinical practice. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT05369988?term = serradilla&draw = 2&rank = 3, [NCT0536998].
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Affiliation(s)
| | | | | | - Esteban Cugat-Andorrá
- Department of Surgery, Hospital Universitario Mutua de Terrassa, Terrassa, Spain
- Department of Surgery, Hospital Universitario German Trials I Pujol, Barcelona, Spain
| | | | - Santiago López-Ben
- Department of Surgery, Hospital Universitario Dr. Josep Trueta, Girona, Spain
| | - Elena Martín-Pérez
- Department of Surgery, Hospital Universitario La Princesa, Madrid, Spain
| | - Luis Sabater
- Department of Surgery, Hospital Clínico Universitario, INCLIVA, Valencia, Spain
| | - José Manuel Ramia
- Department of Surgery, Hospital General Universitario Dr. Balmis, ISABIAL, Universidad Miguel Hernández, Alicante, Spain
| | - Mario Serradilla-Martín
- Department of Surgery, Instituto de Investigación Sanitaria Aragón, Hospital Universitario Miguel Servet, Zaragoza, Spain
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