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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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Davey MG, Joyce WP. Evaluating the safety profile of anti-platelet therapy in patients undergoing elective inguinal hernia repair: a systematic review and meta-analysis. Ir J Med Sci 2024; 193:897-902. [PMID: 37526871 PMCID: PMC10961273 DOI: 10.1007/s11845-023-03480-w] [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: 06/23/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION There remains no consensus surrounding the safety of prescribing anti-platelet therapies (APT) prior to elective inguinal hernia repair (IHR). AIMS To perform a systematic review and meta-analysis evaluating the safety profile of APT use in patients indicated to undergo elective IHR. METHODS A systematic review was performed in accordance with PRISMA guidelines. Meta-analyses were performed using the Mantel-Haenszel method using the Review Manager version 5.4 software. RESULTS Five studies including outcomes in 344 patients were included. Of these, 65.4% had APT discontinued (225/344), and 34.6% had APT continued (119/344). The majority of included patients were male (94.1%, 288/344). When continuing or discontinuing APT, there was no significant difference in overall haemorrhage rates (odds ratio (OR): 1.86, 95% confidence interval (CI): 0.29-11.78, P = 0.130) and in sensitivity analysis using only RCT data (OR: 0.63, 95% CI: 0.03-12.41, P = 0.760). Furthermore, there was no significant difference in reoperation rates (OR: 6.27, 95% CI: 0.72-54.60, P = 0.590); however, a significant difference was observed for readmission rates (OR: 5.67, 95% CI: 1.33-24.12, P = 0.020) when APT was continued or stopped pre-operatively. There was no significant difference in the estimated blood loss, intra-operative time, transfusion of blood products, rates of complications, cerebrovascular accidents, myocardial infarctions, or mortality observed. CONCLUSION This study illustrates the safety of continuing APT pre-operatively in patients undergoing elective IHR, with similar rates of haemorrhage, reoperation, and readmission observed. Clinical trials with larger patient recruitment will be required to fully establish the safety profile of prescribing APT in the pre-operative setting prior to elective IHR.
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Affiliation(s)
- Matthew G Davey
- Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland.
| | - William P Joyce
- Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland
- Department of Surgery, Galway Clinic, Co., Galway, H91 HHT0, Ireland
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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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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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Yong CW, Tan SHX, Teo GN, Tan TS, Ng WH. Should we stop dual anti-platelet therapy for dental extractions? An umbrella review for this dental dilemma. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e708-e716. [PMID: 35691560 DOI: 10.1016/j.jormas.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 05/28/2022] [Accepted: 06/08/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Dual Anti-platelet Therapy (DAPT) are prescribed to patients who had or are at risk of cerebrovascular or cardiovascular ischemic events. This umbrella review appraises existing systematic reviews on the risk of bleeding related complications during and after dental extractions for patients on DAPT. STUDY DATA AND SOURCES This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered to the PROSPERO (International prospective register of systematic reviews) database. A systematic electronic literature search was conducted according to the PRISMA guidelines, via PubMed, Ovid, Cochrane and Embase. STUDY SELECTION Four systematic reviews met the inclusion criteria and were included the analysis. They show DAPT increases the risk of bleeding related complications after dental extractions, but the differences may not be clinically significant as local haemostatic measures were adequate in controlling bleeding. CONCLUSION Despite the increased risk of bleeding after dental extractions in patients on DAPT, it may not be necessary to interrupt the anti-platelet therapy. Local haemostatic agents may be sufficient in controlling both the primary or secondary bleeding. On the other hand, the complications of discontinuing DAPT may be more severe and fatal.
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Affiliation(s)
- Chee Weng Yong
- Discipline of Oral Maxillofacial Surgery, Faculty of Dentistry, National University Centre for Oral Health, 9 Lower Kent Ridge Road, 119085, Singapore
| | - Sharon Hui Xuan Tan
- Saw Swee Hock School of Public Health, National University of Singapore, 16 Medical Dr,117597, Singapore; School of Health and Social Sciences (Oral Health Therapy), Nanyang, Polytechnic, Singapore
| | - Guo Nian Teo
- Department of Oral & Maxillofacial Surgery, National Dental Centre Singapore, 5 Second Hospital Avenue, 168938, Singapore
| | - Teng Seng Tan
- Department of Oral & Maxillofacial Surgery, National Dental Centre Singapore, 5 Second Hospital Avenue, 168938, Singapore
| | - Wee Hsuan Ng
- Discipline of Oral Maxillofacial Surgery, Department of Dentistry, Khoo Teck Puat Hospital, Level 1, 90 Yishun Central, 768828, Singapore.
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Preoperative echocardiogram does not increase time to surgery in hip fracture patients with prior percutaneous coronary intervention. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1013-1022. [PMID: 35279771 DOI: 10.1007/s00590-022-03245-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The purpose of this study was to (1) assess the effect of preoperative echocardiogram on time to surgery and (2) assess the outcomes of patients with a previous percutaneous coronary intervention (PCI). METHODS Demographic, clinical, quality and cost data were obtained and a validated risk predictive tool (STTGMA) was calculated for each of a consecutive series of hip fracture patients. Comparative analyses of patients who had an echocardiogram prior to surgery or a PCI prior to hospitalization were performed. RESULTS Between 2014 and 2020, 2625 patients presented to our institution with a hip fracture. From this cohort 471 patients underwent a preoperative transthoracic echocardiogram (TTE), 30 who had a history of a PCI, and an additional 26 who had a history of PCI but did not undergo a preoperative TTE. Those undergoing a preoperative TTE had similar time (days) to surgery (1.73 vs 1.77, p = 0.86) and 30-day mortality (4% vs 7%, p = 0.545) regardless of PCI history. PCI patients who underwent a preoperative TTE experienced increased rates of 1-year mortality (27% vs 10%, p = 0.007) and major complications (23% vs 12%, p = 0.08) compared to those without a PCI history. PCI patients undergoing a preoperative TTE had a similar time (days) to surgery (1.77 vs 1.48, .p = 0.397) compared to PCI patients without a preoperative TTE. Patients who underwent a preoperative TTE had higher rates of 90-day readmission (31.0% vs 8.0%, p = 0.047) and 1-year mortality (26.7% vs 3.8%, p = 0.029). CONCLUSIONS Having a preoperative TTE does not affect surgical wait times in hip fracture patients regardless of PCI history, but it may not improve mortality outcomes or reduce postoperative complications in patients with a history of a PCI.
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Cole WW, Familia M, Miskimin C, Mulcahey MK. Preoperative Optimization and Tips to Avoiding Surgical Complications Before the Incision. Sports Med Arthrosc Rev 2022; 30:2-9. [PMID: 35113836 DOI: 10.1097/jsa.0000000000000336] [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: 11/26/2022]
Abstract
In preparation for surgery, it is important for surgeons to have a detailed discussion with patients about the risks, benefits, and alternatives to surgery. Patient optimization, ensuring the patient is in the best medical condition before surgery, is also an important aspect of patient care that the surgeon must consider. Although complications cannot be eliminated, there are often opportunities to optimize patients, so these risks can be minimized based on current evidence-based medicine. To minimize the risk of complications, the surgeon should take an active role in each step of the patient's care beginning with the history and physical examination, obtaining the correct preoperative labs, and continuing through positioning, draping, and prepping before making an incision.
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Affiliation(s)
- Wendell W Cole
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
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Saka E, Canbaz M, Abdullah T, Dinc T, Polat O, Sabanci PA, Akinci IO, Tugrul KM, Ali A. Perioperative myocardial injury after elective neurosurgery: incidence, risk factors, and effects on mortality. Neurosurg Rev 2022; 45:2151-2159. [PMID: 35018524 DOI: 10.1007/s10143-021-01722-y] [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: 05/25/2021] [Revised: 11/20/2021] [Accepted: 12/20/2021] [Indexed: 10/19/2022]
Abstract
Perioperative myocardial injury is an important reason of mortality and morbidity after neurosurgery. It usually is missed due to its asymptomatic character. In the present study, we investigated myocardial injury after noncardiac surgery (MINS) incidence, the risk factor for MINS, and association of MINS with 30-day mortality in neurosurgery patients. Patients with cardiac risk who underwent elective neurosurgery were enrolled to present prospective cohort study. The patients' demographics, comorbidities, medications used, medical history, and type of operation were recorded. The high-sensitivity cardiac troponin (hs-cTn) levels of the patients were measured 12, 24, and 48 h after surgery. The patients were considered MINS-positive if at least one of their postoperative hs-cTn measurement values was ≥ 14 ng/l. All the patients were followed up for 30 days after surgery for evaluation of their outcomes, including total mortality, mortality due to cardiovascular cause, and major cardiac events. A total of 312 patients completed the study and 64 (20.5%) of them was MINS-positive. Long antiplatelet or anticoagulant drug cessation time (OR: 4.9, 95% CI: 2.1-9.4) was found the most prominent risk factor for MINS occurrence. The total mortality rate was 2.4% and 6.2% in patients MINS-negative and MINS-positive, respectively (p = 0.112). The mortality rate due to cardiovascular reasons (0.8% for without MINS, 4.7 for with MINS, and p = 0.026) and incidence of the major cardiac events (4% for without MINS, 10.9 for with MINS, and p = 0.026) were significantly higher in patients with MINS. MINS is a common problem after neurosurgery, and high postoperative hs-cTn level is associated with mortality and morbidity.
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Affiliation(s)
- Esra Saka
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Mert Canbaz
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Taner Abdullah
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Tugce Dinc
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Ozlem Polat
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Pulat Akin Sabanci
- Department of Neurosurgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ibrahim Ozkan Akinci
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Kamil Mehmet Tugrul
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Achmet Ali
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey. .,İ.Ü. İstanbul Tıp Fakültesi Anesteziyoloji A.D., Turgut Özal cad, İstanbul, Türkiye.
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Riscado LVS, de Pinho JHS, Lobato ADC. Efficacy and safety of tirofiban bridge as an alternative to suspension of dual antiplatelet therapy in patients undergoing surgery: a systematic review. J Vasc Bras 2021; 20:e20210113. [PMID: 34925474 PMCID: PMC8668084 DOI: 10.1590/1677-5449.210113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/08/2021] [Indexed: 11/22/2022] Open
Abstract
Use of a tirofiban bridge is an alternative to simply withdrawing dual antiplatelet therapy prior to operating on patients at high risk of stent thrombosis and bleeding. We aimed to evaluate the efficacy and safety of this protocol in patients undergoing surgery within 12 months of a percutaneous coronary intervention involving stenting. We performed a systematic review based on searches of the PubMed, Web of Science, Cochrane, Embase, Lilacs, and Scielo databases and of the references of relevant articles on the topic. Five of the 107 studies identified were included after application of eligibility criteria and analysis of methodological quality, totaling 422 patients, 227 in control groups. Notwithstanding the limitations reported, four of the five studies included indicate that the tirofiban bridge technique is effective for reducing adverse cardiac events and is safe in terms of not interfering with the risk of hemorrhagic events or bleeding. However, randomized clinical trials are needed to provide robust evidence.
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Ganesh R, Kebede E, Mueller M, Gilman E, Mauck KF. Perioperative Cardiac Risk Reduction in Noncardiac Surgery. Mayo Clin Proc 2021; 96:2260-2276. [PMID: 34226028 DOI: 10.1016/j.mayocp.2021.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 02/20/2021] [Accepted: 03/04/2021] [Indexed: 11/21/2022]
Abstract
Major adverse cardiovascular events are a significant source of morbidity and mortality in the perioperative setting, estimated to occur in approximately 5% of patients undergoing nonemergent noncardiac surgery. To minimize the incidence and impact of these events, careful attention must be paid to preoperative cardiovascular assessment to identify patients at high risk of cardiovascular complications. Once identified, cardiovascular risk reduction is achieved through optimization of medical conditions, appropriate management of medication, and careful monitoring to allow for early identification of-and intervention for-any new conditions that would increase the risk of adverse cardiovascular outcomes. The major cardiovascular and anesthesiology societies in the United States, Europe, and Canada have published guidelines for perioperative management of patients undergoing noncardiac surgery. However, since publication of these guidelines, there has been a practice-changing evolution in the medical literature. In this review, we attempt to reconcile the recommendations made in these 3 comprehensive guidelines, while updating recommendations, based on new evidence, when available.
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Affiliation(s)
- Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Esayas Kebede
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Elizabeth Gilman
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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Sunu VS, Roshni A, Ummar M, Aslam SA, Nair RB, Thomas T. A longitudinal study to evaluate the bleeding pattern of patients on low dose aspirin therapy following dental extraction. J Family Med Prim Care 2021; 10:1399-1403. [PMID: 34041185 PMCID: PMC8140285 DOI: 10.4103/jfmpc.jfmpc_312_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/19/2020] [Accepted: 04/02/2020] [Indexed: 11/12/2022] Open
Abstract
Background and Aims: Antiplatelet dugs are often interrupted preceding invasive dental extraction because of concern of bleeding complications. The fear of uncontrolled bleeding often prompts medical and dental practitioners to stop aspirin intake for 7 to 10 days before any surgical procedure, which puts the patient at risk from adverse thrombotic events. The aim of the study conducted was to evaluate the bleeding pattern after routine dental extraction among patients on low dose long term aspirin therapy. Methods: A total of 104 subjects in the age group of 30-65 years, who continued to have aspirin intake during extraction were included in the study. Dental extraction was performed without stopping aspirin therapy under local anesthesia. The post-operative blood loss was quantified by weighing the gauze pre and post operatively and adding total volume of fluid in the suction jar. Results: Of these 104 patients treated, 87% of patients had mild bleeding (<20 ml) and 13% of patients had moderate bleeding (20-30 ml). The total study population showed a mean blood loss of 16.15 ± 3.5 ml. Conclusion: Within in the limitations, our study concluded that the routine dental extraction in patients under low dose aspirin therapy did not cause clinically significant post extraction hemorrhage. Aspirin intake can be continued during routine dental extraction as post extraction bleeding encountered will be negligible.
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Affiliation(s)
- V S Sunu
- Department of Oral and Maxillofacial Surgery, MES Dental College, Perinthalmanna, Kerala, India
| | - A Roshni
- Department of Oral and Maxillofacial Surgery, MES Dental College, Perinthalmanna, Kerala, India
| | - M Ummar
- Department of Oral and Maxillofacial Surgery, MES Dental College, Perinthalmanna, Kerala, India
| | - Sachin A Aslam
- Department of Oral and Maxillofacial Surgery, MES Dental College, Perinthalmanna, Kerala, India
| | - Rakesh B Nair
- Department of Oral and Maxillofacial Surgery, MES Dental College, Perinthalmanna, Kerala, India
| | - Tom Thomas
- Department of Oral and Maxillofacial Surgery, MES Dental College, Perinthalmanna, Kerala, India
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Belcher A, Zulfiker AHM, Li OQ, Yue H, Gupta AS, Li W. Targeting Thymidine Phosphorylase With Tipiracil Hydrochloride Attenuates Thrombosis Without Increasing Risk of Bleeding in Mice. Arterioscler Thromb Vasc Biol 2021; 41:668-682. [PMID: 33297751 PMCID: PMC8105268 DOI: 10.1161/atvbaha.120.315109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Current antiplatelet medications increase the risk of bleeding, which leads to a clear clinical need in developing novel mechanism-based antiplatelet drugs. TYMP (Thymidine phosphorylase), a cytoplasm protein that is highly expressed in platelets, facilitates multiple agonist-induced platelet activation, and enhances thrombosis. Tipiracil hydrochloride (TPI), a selective TYMP inhibitor, has been approved by the Food and Drug Administration for clinical use. We tested the hypothesis that TPI is a safe antithrombotic medication. Approach and Results: By coexpression of TYMP and Lyn, GST (glutathione S-transferase) tagged Lyn-SH3 domain or Lyn-SH2 domain, we showed the direct evidence that TYMP binds to Lyn through both SH3 and SH2 domains, and TPI diminished the binding. TYMP deficiency significantly inhibits thrombosis in vivo in both sexes. Pretreatment of platelets with TPI rapidly inhibited collagen- and ADP-induced platelet aggregation. Under either normal or hyperlipidemic conditions, treating wild-type mice with TPI via intraperitoneal injection, intravenous injection, or gavage feeding dramatically inhibited thrombosis without inducing significant bleeding. Even at high doses, TPI has a lower bleeding side effect compared with aspirin and clopidogrel. Intravenous delivery of TPI alone or combined with tissue plasminogen activator dramatically inhibited thrombosis. Dual administration of a very low dose of aspirin and TPI, which had no antithrombotic effects when used alone, significantly inhibited thrombosis without disturbing hemostasis. CONCLUSIONS This study demonstrated that inhibition of TYMP, a cytoplasmic protein, attenuated multiple signaling pathways that mediate platelet activation, aggregation, and thrombosis. TPI can be used as a novel antithrombotic medication without the increase in risk of bleeding.
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Affiliation(s)
- Adam Belcher
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine of Marshall University, Huntington, WV, 25755, USA
| | - Abu Hasanat Md Zulfiker
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine of Marshall University, Huntington, WV, 25755, USA
| | - Oliver Qiyue Li
- Marshall Institute for Interdisciplinary Research; Huntington, WV, 25701, USA
| | - Hong Yue
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine of Marshall University, Huntington, WV, 25755, USA
| | - Anirban Sen Gupta
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland OH 44106, USA
| | - Wei Li
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine of Marshall University, Huntington, WV, 25755, USA
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Griffiths R, Babu S, Dixon P, Freeman N, Hurford D, Kelleher E, Moppett I, Ray D, Sahota O, Shields M, White S. Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists. Anaesthesia 2020; 76:225-237. [PMID: 33289066 DOI: 10.1111/anae.15291] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2020] [Indexed: 12/26/2022]
Abstract
We convened a multidisciplinary Working Party on behalf of the Association of Anaesthetists to update the 2011 guidance on the peri-operative management of people with hip fracture. Importantly, these guidelines describe the core aims and principles of peri-operative management, recommending greater standardisation of anaesthetic practice as a component of multidisciplinary care. Although much of the 2011 guidance remains applicable to contemporary practice, new evidence and consensus inform the additional recommendations made in this document. Specific changes to the 2011 guidance relate to analgesia, medicolegal practice, risk assessment, bone cement implantation syndrome and regional review networks. Areas of controversy remain, and we discuss these in further detail, relating to the mode of anaesthesia, surgical delay, blood management and transfusion thresholds, echocardiography, anticoagulant and antiplatelet management and postoperative discharge destination. Finally, these guidelines provide links to supplemental online material that can be used at readers' institutions, key references and UK national guidance about the peri-operative care of people with hip and periprosthetic fractures during the COVID-19 pandemic.
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Affiliation(s)
- R Griffiths
- Department of Anaesthesia, Peterborough and Stamford Hospitals NHS Trust Peterborough, UK and Chair, Working Party, Association of Anaesthetists, UK
| | - S Babu
- Department of Anaesthesia, Warrington and Halton Hospitals NHS Trust, Warrington, UK
| | - P Dixon
- Department of Trauma and Orthopaedics, South Tyneside and Sunderland NHS Trust, Sunderland, UK and British Orthopaedic Association, Orthopaedic Trauma Society, UK
| | - N Freeman
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Hurford
- Department of Anaesthesia, Cwm Taf Morgannwg University Health Board and Chair, Welsh Frailty Fracture Network, UK, UK
| | - E Kelleher
- Department of Anaesthesia, University of Galway, Galway, Ireland
| | - I Moppett
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, UK.,Department of Anaesthesia, Nottingham University Hospitals, Nottingham, UK
| | - D Ray
- Department of Anaesthesia, Royal Infirmary Edinburgh and Honorary Clinical Senior Lecturer, University of Edinburgh, Edinburgh, UK
| | - O Sahota
- Department of Healthcare of Older People, Nottingham University Hospitals, Nottingham, UK and British Geriatrics Society, UK
| | - M Shields
- Department of Anaesthesia, Royal Hospitals, Belfast, UK
| | - S White
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Kim JH, Choi JI. Perioperative dual antiplatelets management for ventriculoperitoneal shunt operation in patients with hydrocephalus after stent-assisted coil embolization of the ruptured intracranial aneurysm. Clin Neurol Neurosurg 2020; 195:106067. [PMID: 32652397 DOI: 10.1016/j.clineuro.2020.106067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/03/2020] [Accepted: 07/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Ventriculoperitoneal shunt (VPS) surgery is sometimes necessary in patients who present with symptomatic hydrocephalus after undergoing stent-assisted coil embolization of ruptured intracranial aneurysms. However, there are no guidelines for the perioperative management of VPS using dual antiplatelet therapy (DAPT) and balancing between the thromboembolic and hemorrhagic complications. Studies regarding discontinuation of DAPT and its substitution with a less potent drug for reducing the risk of hemorrhage have been previously attempted; however, the sample size in these studies was small. This study investigates the safety and feasibility of ibuprofen bridging therapy with discontinuation of DAPT for five days in patients who have recently received a neurovascular stent and require VPS. METHODS Forty-one patients, who were administered DAPT after neurovascular stent placement and later underwent VPS, were retrospectively enrolled. Patients were divided into two groups based on the perioperative DAPT therapy: (1) Bridge: discontinuing DAPT and substituting it with ibuprofen 600 mg bid for five days, and (2) Continue: maintaining DAPT during surgery. The groups were compared and risk factors for hemorrhagic complication were investigated. RESULTS On comparison analysis, no ischemic complications were observed in both groups; however, hemorrhagic complications were significantly higher in the continue than in the bridge group (p = 0.004). On multivariate logistic regression analysis, "ibuprofen bridging" was identified as a significant factor negatively associated with hemorrhagic complications (p = 0.019). CONCLUSION "Ibuprofen bridging therapy with discontinuation of DAPT for 5 days" is a potential treatment strategy for patients having recently undergone neurovascular stent placement and are scheduled for VPS surgery.
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Affiliation(s)
- Jang Hun Kim
- Trauma Center, Armed Forces Capital Hospital, Gyeonggi-do, Republic of Korea
| | - Jong-Il Choi
- Department of Neurosurgery, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
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15
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Smith BB, Warner MA, Warner NS, Hanson AC, Smith MM, Rihal CS, Gulati R, Bell MR, Nuttall GA. Cardiac Risk of Noncardiac Surgery After Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents. Anesth Analg 2019; 128:621-628. [PMID: 30169404 DOI: 10.1213/ane.0000000000003408] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) with stenting is sometimes associated with major adverse cardiac events (MACEs). Second-generation drug-eluting stents (DES) were developed to decrease the incidence of MACE seen with bare metal and first-generation DES. METHODS The medical records of all adult patients who underwent second-generation DES placement between July 29, 2008 and July 28, 2011 followed by NCS between September 22, 2008 and July 1, 2013 were reviewed. All episodes of MACE following surgery were recorded. RESULTS A total of 282 patients (74.8% male) were identified who underwent NCS after PCI with second-generation DES. MACE occurred in 15 patients (5.3%), including 11 deaths. The incidence of MACE changed significantly with time from PCI to NCS: 17.1%, 10.0%, 0.0%, and 3.1% for patients undergoing NCS at 0-90, 91-180, 181-365, and ≥366 days, respectively. Compared with those having NCS ≥366 days after PCI, the odds ratio for MACE (95% confidence interval) was 6.4 (1.9 to 21.3) at 0-90 days and 3.4 (0.8 to 15.3) at 91-180 days. Seven days prior to NCS, 146 (52%) patients were on dual antiplatelet therapy (DAPT), 106 (38%) were on aspirin, and 30 (11%) did not receive antiplatelet therapy. Excessive surgical bleeding occurred in 19 cases (6.7%). While observed bleeding rates were lowest in those not receiving antiplatelet therapy, there were no statistically significant differences based on the presence or absence of antiplatelet therapy (3% [1/30] for no antiplatelet therapy compared to 6% [6/106] for aspirin monotherapy and 8% [12/146] for DAPT; Fisher exact test: P = .655). CONCLUSIONS The incidence of MACE in patients with second-generation DES undergoing NCS was 5.3% and was highest in the first 180 days following DES implantation. The rate of excessive surgical bleeding was 6.7% with the highest observed rate in those on DAPT. However, differences by the presence or absence of antiplatelet therapy were not significant, and future large observational studies will be necessary to further define bleeding risk with continued DAPT.
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Affiliation(s)
- Bradford B Smith
- From the Department of Anesthesiology and Perioperative Medicine
| | - Matthew A Warner
- From the Department of Anesthesiology and Perioperative Medicine
| | | | | | - Mark M Smith
- From the Department of Anesthesiology and Perioperative Medicine
| | - Charanjit S Rihal
- Division of Cardiology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajiv Gulati
- Division of Cardiology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Division of Cardiology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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16
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Cangrelor Bridging Within 6 Months of a Drug-Eluting Stent in a Patient for Emergency Cervical Spine Surgery: A Case Report. A A Pract 2019; 13:69-73. [PMID: 30864953 DOI: 10.1213/xaa.0000000000000994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The recommended duration of dual antiplatelet therapy after drug-eluting stent placement presents a dilemma for patients with recent stenting who require urgent or emergency noncardiac surgery. We present the case of a patient with recent drug-eluting stent placement (<6 months) on dual antiplatelet therapy who underwent successful emergency cervical spine surgery with antiplatelet therapy bridged using cangrelor, an intravenous P2Y12 inhibitor antiplatelet agent. Our experience illustrates the multidisciplinary approach to a patient with high thrombotic and bleeding risk who underwent neurosurgery off both aspirin and a P2Y12 inhibitor.
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17
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Yu WS, Lee CY. Safety of perioperative low dose aspirin therapy in major lung resection. J Thorac Dis 2019; 11:S1897-S1899. [PMID: 31632779 DOI: 10.21037/jtd.2019.08.43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Woo Sik Yu
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Chang Young Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Yonsei University, Seoul, Republic of Korea
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18
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Raggio BS, Barton BM, Kandil E, Friedlander PL. Association of Continued Preoperative Aspirin Use and Bleeding Complications in Patients Undergoing Thyroid Surgery. JAMA Otolaryngol Head Neck Surg 2019; 144:335-341. [PMID: 29494736 DOI: 10.1001/jamaoto.2017.3262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance No evidence exists to direct the management of preoperative aspirin (acetylsalicylic acid) use in patients undergoing thyroid surgery. Nevertheless, a considerable number of patients interrupt receiving aspirin therapy during the preoperative period to minimize bleeding complications despite the increased risk of experiencing major adverse cardiac events. Objective To determine whether aspirin therapy continued preoperatively increases bleeding complications in patients undergoing thyroid surgery. Design, Setting, and Participants Retrospective analysis of a consecutive sample of 570 patients, aged 18 to 100 years, who underwent thyroid surgery for benign and malignant disease from January 1, 2010, to December 31, 2015, by a single surgeon at a tertiary referral hospital center in New Orleans, Louisiana. Exposures Patients receiving aspirin therapy and patients not receiving aspirin therapy (aspirin naive) preoperatively. Main Outcomes and Measures Comparison of estimated blood loss, substantial blood loss, operative hematoma, nonoperative hematoma, and recurrent laryngeal nerve injury. Results Of 570 patients who underwent thyroid surgery, 106 (18.6%) were performed in patients receiving aspirin; of these, 23 (21.7%) were men and 105 (99.1%) were older than 45 years. Those receiving aspirin therapy displayed a 14.4-year difference in age (95% CI, 11.6-17.1). The aspirin group displayed a 20.3% absolute increase (95% CI, 9.3-30.7) in African American patients. Aspirin therapy was not associated with a statistically significant or clinically meaningful increase in intraoperative blood loss (2.5 mL; 95% CI, -0.4 to 5.3). Aspirin therapy was associated with a statistically significant increase in total hematoma formation (3.3%; 95% CI, 0.4-9.0), but the results were inconclusive. Aspirin therapy was not associated with a statistically significant increase in recurrent laryngeal nerve injury (2.6%; 95% CI, -1.1 to 8.6), but the results were inconclusive. Conclusions and Relevance These results suggest that aspirin therapy can be maintained prior to thyroid surgery without increased intraoperative bleeding. Further research with a larger sample size and more outcome events are required to make definitive conclusions regarding the association between aspirin use and complications, including hematoma and recurrent laryngeal nerve injury.
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Affiliation(s)
- Blake S Raggio
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
| | - Blair M Barton
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
| | - Emad Kandil
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
| | - Paul L Friedlander
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
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19
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Pennestrì F, Maffulli N, Sirtori P, Perazzo P, Negrini F, Banfi G, Peretti GM. Blood management in fast-track orthopedic surgery: an evidence-based narrative review. J Orthop Surg Res 2019; 14:263. [PMID: 31429775 PMCID: PMC6701001 DOI: 10.1186/s13018-019-1296-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 07/25/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research. METHODS AND MATERIALS We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital. RESULTS Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction. CONCLUSION The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.
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Affiliation(s)
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Fisciano, Italy. .,San Giovanni di Dio e Ruggi D'Aragona Hospital "Clinica Orthopedica" Department, Hospital of Salerno, Salerno, Italy. .,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, London, England.
| | - Paolo Sirtori
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Paolo Perazzo
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Francesco Negrini
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Giuseppe Banfi
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy.,Vita-Salute San Raffaele University, Scientific Direction, Milan, Italy
| | - Giuseppe M Peretti
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy.,University of Milan, Department of Biomedical Sciences for Health, Milan, Italy
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20
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Li J, Wang M, Cheng T. The safe and risk assessment of perioperative antiplatelet and anticoagulation therapy in inguinal hernia repair, a systematic review. Surg Endosc 2019; 33:3165-3176. [DOI: 10.1007/s00464-019-06956-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/01/2019] [Indexed: 01/30/2023]
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21
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Carneiro A, Cha JD, Baccaglini W, Husain FZ, Wroclawski ML, Nunes-Silva I, Sanchez-Salas R, Ingels A, Kayano PP, Claros OR, Saviano Moran NK, Sotelo R, Lemos GC. Should aspirin be suspended prior to robot-assisted radical prostatectomy? A systematic review and meta-analysis. Ther Adv Urol 2019; 11:1756287218816595. [PMID: 30671139 PMCID: PMC6329037 DOI: 10.1177/1756287218816595] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 11/06/2018] [Indexed: 12/03/2022] Open
Abstract
Background: Low-dose aspirin use has been correlated with an increased risk of bleeding and overall complications in surgical and invasive diagnostic procedures. In this review, our aim was to analyze the current literature on whether robot-assisted radical prostatectomy (RARP) is feasible and safe in patients taking low-dose aspirin perioperatively. Methods: A systematic review was performed identifying a total of 767 studies, published between January 2000 and September 2017, with five of these studies meeting the inclusion criteria for the meta-analysis, totalizing 1481 patients underwent RARP. Patients were divided into two groups: taking aspirin (group A) and those not taking aspirin (group B) perioperatively. Results: There were no significant differences between groups in the overall [group A 10.7% versus group B 15.7%, risk ratio (RR) 0.83; p = 0.45; I2 = 0%] or major complication rates (group A 1% versus group B 3%, RR 0.98; p = 0.98; I² = 0%), rate of cardiovascular events (group A 1.4% and group B 0.5%, RR 2.06; p = 0.24; I2 = 9%), blood loss (group A 278 ml versus group B 307 ml, SMD −0.12; p = 0.91; I2 = 96%), or hospital length of stay [group A 4 days (3–5) and group B 4 days (3–4), SMD −0.09; p = 0.52; I² = 0%]. There was a slightly higher blood-transfusion rate in group A (2.6%) versus group B (1.6%) (RR, 5.05; p = 0.04; I2 = 0%). Conclusion: Continued aspirin use in the perioperative period does not correlate with an increase in surgical morbidity, blood loss, or hospital length of stay. There was a slightly higher blood-transfusion rate in patients taking low-dose aspirin (group A) perioperatively.
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Affiliation(s)
- Arie Carneiro
- Israelita Albert Einstein Hospital, São Paulo, Brazil Discipline of Urology, ABC Medical School, São Paulo, Brazil
| | - Jonathan Doyun Cha
- Israelita Albert Einstein Hospital, São Paulo, Brazil Discipline of Urology, ABC Medical School, São Paulo, Brazil
| | - Willy Baccaglini
- Discipline of Urology - ABC Medical School, Av. Lauro Gomes, 2000 - Anexo II, Vila Sacadura Cabral - Santo André/SP, CEP: 09060-870, Brazil
| | - Fatima Z Husain
- Institute of Urology, University of Southern California, Los Angeles, California, USA
| | - Marcelo Langer Wroclawski
- Israelita Albert Einstein Hospital, São Paulo, Brazil Discipline of Urology, ABC Medical School, São Paulo, Brazil
| | - Igor Nunes-Silva
- Arnaldo Vieira de Carvalho Cancer Institute - IAVC, São Paulo, Brazil
| | | | - Alexandre Ingels
- Department of Urology, Institut Mutualiste Montsouris, Paris, France
| | | | | | | | - René Sotelo
- Institute of Urology, University of Southern California, Los Angeles, California, USA
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22
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Touny M, Catros S, Fricain JC, Fénelon M. Perioperative management of patients undergoing antithrombotic treatment in oral surgery in France: a survey. JOURNAL OF ORAL MEDICINE AND ORAL SURGERY 2019. [DOI: 10.1051/mbcb/2019024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction: The prevention and treatment of thromboembolic events is generally based on the prescription of antithrombotics. These drugs are associated with an increased hemorrhagic risk. The procedures for the management of patients under antithrombotic treatment are described in the recommendations of the Société Française de Chirurgie Orale (SFCO), published in 2015. The main objective of this study was to describe dentists' knowledge and practices regarding the perioperative management of patients under antithrombotic agents in oral surgery in France. Materials and methods: A national cross-sectional study was conducted between June and September 2018. An electronic questionnaire was created on Google Forms and sent through social networks. Results: In total, 185 responses were collected. Two-thirds of the respondents reported that they were aware of the 2015 recommendations. Ten respondents reported that they did not manage patients treated with antithrombotic drugs. Among the respondents who managed such patients, 25% and 16% ordered hemostasis tests for patients treated with direct anticoagulants and antiplatelet agents, respectively. Discussion: Although 71% of dentists considered themselves properly informed, one-third stated that they were not aware of SFCO's 2015 recommendations. Among those who were aware of these recommendations, 47% correctly ordered hemostasis tests before surgery in patients on antithrombotic medication. Conclusion: This study indicates that there is a lack of knowledge and noncompliance with the recommendations among at least half the sample population regarding perioperative management of patients on antithrombotic therapy.
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23
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Sierra P, Gómez-Luque A, Llau JV, Ferrandis R, Cassinello C, Hidalgo F. Recommendations for perioperative antiplatelet treatment in non-cardiac surgery. Working Group of the Spanish Society of Anaesthesiology-Resuscitation and Pain Therapy, Division of Haemostasis, Transfusion Medicine, and Perioperative Fluid Therapy. Update of the Clinical practice guide 2018. ACTA ACUST UNITED AC 2018; 66:18-36. [PMID: 30166124 DOI: 10.1016/j.redar.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 12/24/2022]
Affiliation(s)
- P Sierra
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Fundación Puigvert (IUNA), Barcelona, España.
| | - A Gómez-Luque
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, España
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Dr. Peset, Universitat de València, Valencia, España
| | - R Ferrandis
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hopital Clínic i Universitari La Fe, Universitat de València, Valencia, España
| | - C Cassinello
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - F Hidalgo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Clínica Universidad de Navarra, Pamplona, España
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Lizaur-Utrilla A, Gonzalez-Navarro B, Vizcaya-Moreno MF, Miralles Muñoz FA, Gonzalez-Parreño S, Lopez-Prats FA. Reasons for delaying surgery following hip fractures and its impact on one year mortality. INTERNATIONAL ORTHOPAEDICS 2018; 43:441-448. [PMID: 29744645 DOI: 10.1007/s00264-018-3936-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/05/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE The purposes of this study were to identify the reasons for delayed surgery following hip fractures and analyze the impact of these reasons on 1-year mortality. METHODS A prospective cohort study of 1234 patients with mean age of 83.1 (range 65-92, SD 8.0) who underwent hip fracture surgery compared three subgroups: (1) surgery within two days from admission (609 patients); (2) delayed surgery for medical reasons (286); and (3) delayed surgery for organizational causes (339). Medical reason was defined as the need of medical optimization of the patient prior to surgery. Pre-operative assessment was performed by the American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), Hodkinson mental status, Katz index for activities of daily living, and Short-Form (SF-12) questionnaire. Univariate analyses were used (chi-square and Fisher exact or Mantel-Haenszel tests for categorical data, and variance analysis, Student t test, or Mann-Whitney U test for continuous data). Logistic regression models were used for influence of variables on complications and one year mortality. RESULTS There were no significant differences in complications or one year mortality rates between patients with surgery within two days and those with delayed surgery for medical reasons. However, the patients with delayed surgery for organizational causes had significant higher rates of both complications and one year mortality compared to the other two groups (p = 0.001). CONCLUSIONS This study suggests that waiting time for hip fracture surgery more than two days was not associated with higher complication or mortality rate if waiting was to stabilize patients with active comorbidities at admission, compared to stable patients at admission with early surgery. Although early surgery within two days from admission is desirable for stable patients at admission, in patients with complex comorbidities, the surgery should be performed once they are optimized. However, the patients with delayed surgery for organizational reasons had a significant higher rate of post-operative complications and one year mortality compared to the other two groups.
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Affiliation(s)
- Alejandro Lizaur-Utrilla
- Orthopaedic Surgery, Elda University Hospital, Miguel Hernandez University, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain. .,Traumatology and Orthopaedia, Miguel Hernandez University, Elche, Alicante, Spain.
| | - Blanca Gonzalez-Navarro
- Orthopaedic Surgery, Elda University Hospital, Miguel Hernandez University, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain
| | - Maria F Vizcaya-Moreno
- Clinical Research Group, Faculty of Health Sciences, University of Alicante, Alicante, Spain
| | - Francisco A Miralles Muñoz
- Orthopaedic Surgery, Elda University Hospital, Miguel Hernandez University, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain
| | - Santiago Gonzalez-Parreño
- Orthopaedic Surgery, Elda University Hospital, Miguel Hernandez University, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain
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25
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Baschin M, Selleng S, Hummel A, Diedrich S, Schroeder HW, Kohlmann T, Westphal A, Greinacher A, Thiele T. Preoperative platelet transfusions to reverse antiplatelet therapy for urgent non-cardiac surgery: an observational cohort study. J Thromb Haemost 2018; 16:709-717. [PMID: 29383871 DOI: 10.1111/jth.13962] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Indexed: 01/22/2023]
Abstract
Essentials An increasing number of patients requiring surgery receive antiplatelet therapy (APT). We analyzed 181 patients receiving presurgery platelet transfusions to reverse APT. No coronary thrombosis occurred after platelet transfusion. This justifies a prospective trial to test preoperative platelet transfusions to reverse APT. SUMMARY Background Patients receiving antiplatelet therapy (APT) have an increased risk of perioperative bleeding and cardiac adverse events (CAE). Preoperative platelet transfusions may reduce the bleeding risk but may also increase the risk of CAE, particularly coronary thrombosis in patients after recent stent implantation. Objectives To analyze the incidence of perioperative CAE and bleeding in patients undergoing non-cardiac surgery using a standardized management of transfusing two platelet concentrates preoperatively and restart of APT within 24-72 h after surgery. Methods A cohort of consecutive patients on APT treated with two platelet concentrates before non-cardiac surgery between January 2012 and December 2014 was retrospectively identified. Patients were stratified by the risk of major adverse cardiac and cerebrovascular events (MACCE). The primary objective was the incidence of CAE (myocardial infarction, acute heart failure and cardiac troponine T increase). Secondary objectives were incidences of other thromboembolic events, bleedings, transfusions and mortality. Results Among 181 patients, 88 received aspirin, 21 clopidogrel and 72 dual APT. MACCE risk was high in 63, moderate in 103 and low in 15 patients; 67 had cardiac stents. Ten patients (5.5%; 95% CI, 3.0-9.9%) developed a CAE (three myocardial infarctions, four cardiac failures and three troponin T increases). None was caused by coronary thrombosis. Surgery-related bleeding occurred in 22 patients (12.2%; 95% CI, 8.2-17.7%), making 12 re-interventions necessary (6.6%; 95% CI, 3.8-11.2%). Conclusion Preoperative platelet transfusions and early restart of APT allowed urgent surgery and did not cause coronary thromboses, but non-thrombotic CAEs and re-bleeding occurred. Randomized trials are warranted to test platelet transfusion against other management strategies.
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Affiliation(s)
- M Baschin
- Abteilung Transfusionsmedizin, Institut für Immunologie und Transfusionsmedizin, Greifswald, Germany
| | - S Selleng
- Klinik für Anästhesiologie, Universitätsmedizin Greifswald, Greifswald, Germany
| | - A Hummel
- Klinik und Poliklinik für Innere Medizin B, Universitätsmedizin Greifswald, Greifswald, Germany
| | - S Diedrich
- Klinik und Poliklinik für Chirurgie, Universitätsmedizin Greifswald, Greifswald, Germany
| | - H W Schroeder
- Klinik für Neurochirurgie, Universitätsmedizin Greifswald, Greifswald, Germany
| | - T Kohlmann
- Institut für Community Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - A Westphal
- Abteilung Transfusionsmedizin, Institut für Immunologie und Transfusionsmedizin, Greifswald, Germany
| | - A Greinacher
- Abteilung Transfusionsmedizin, Institut für Immunologie und Transfusionsmedizin, Greifswald, Germany
| | - T Thiele
- Abteilung Transfusionsmedizin, Institut für Immunologie und Transfusionsmedizin, Greifswald, Germany
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Use of aspirin and bleeding-related complications after hepatic resection. Br J Surg 2018; 105:429-438. [DOI: 10.1002/bjs.10697] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 07/08/2017] [Accepted: 08/22/2017] [Indexed: 12/22/2022]
Abstract
Abstract
Background
The operative risk of hepatectomy under antiplatelet therapy is unknown. This study sought to assess the outcomes of elective hepatectomy performed with or without aspirin continuation in a well balanced matched cohort.
Methods
Data were retrieved from a multicentre prospective observational study. Aspirin and control groups were compared by non-standardized methods and by propensity score (PS) matching analysis. The main outcome was severe (Dindo–Clavien grade IIIa or more) haemorrhage. Other outcomes analysed were intraoperative transfusion, overall haemorrhage, major morbidity, comprehensive complication index (CCI) score, thromboembolic complications, ischaemic complications and mortality.
Results
Before matching, there were 118 patients in the aspirin group and 1685 in the control group. ASA fitness grade, cardiovascular disease, previous history of angina pectoris, angioplasty, diabetes, use of vitamin K antagonists, cirrhosis and type of hepatectomy were significantly different between the groups. After PS matching, 108 patients were included in each group. There were no statistically significant differences between the aspirin and control groups in severe haemorrhage (6·5 versus 5·6 per cent respectively; odds ratio (OR) 1·18, 95 per cent c.i. 0·38 to 3·62), intraoperative transfusion (23·4 versus 23·7 per cent; OR 0·98, 0·51 to 1·87), overall haemorrhage (10·2 versus 12·0 per cent; OR 0·83, 0·35 to 1·94), CCI score (24 versus 28; P = 0·520), major complications (23·1 versus 13·9 per cent; OR 1·82, 0·92 to 3·79) and 90-day mortality (5·6 versus 4·6 per cent; OR 1·21, 0·36 to 4·09).
Conclusion
This observational study suggested that aspirin continuation is not associated with a higher rate of bleeding-related complications after elective hepatic surgery.
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Blackshaw WJ, Bhawnani A, Pennefather SH, Al-Rawi O, Agarwal S, Shaw M. Propensity score-matched outcomes after thoracic epidural or paravertebral analgesia for thoracotomy. Anaesthesia 2018; 73:444-449. [DOI: 10.1111/anae.14205] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2017] [Indexed: 11/27/2022]
Affiliation(s)
- W. J. Blackshaw
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
| | - A. Bhawnani
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
| | - S. H. Pennefather
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
| | - O. Al-Rawi
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
| | - S. Agarwal
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
| | - M. Shaw
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
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Kusljic S, Aneja J, Manias E. Incidence of complications in men undergoing transurethral resection of the prostate. Collegian 2017; 24:3-9. [PMID: 29218956 DOI: 10.1016/j.colegn.2015.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Objectives To examine the link between medication use and the risk of bleeding complications following transurethral resection of the prostate from the second postoperative day until hospital discharge. Method Using a retrospective observational study design, the medical records of all patients who underwent transurethral resection of the prostate over a 24-month period were examined. Comprehensive data regarding patients’ medication history, comorbidities and complications that occurred either during or after surgery were collected from medical records. Inferential statistical analysis was used to examine associations between demographic and medication variables and the risk of complications. Results Complications arising after surgery occurred in 48/135 (36%) of patients. The most common complications postoperatively were hematuria, occurring in 41/48 (85%) and hematuria with clot retention, occurring in 24/48 (50%) of patients who suffered complications. There was a significant association between the number of medications prescribed and postoperative complications; for hematuria, χ2 (12) = 21.50, p = 0.04; and for hematuria with clot retention χ2 (12) = 24.97, p = 0.015. Conclusions Demographic data relating to patients’ age, comorbid state and the number of standard medications prescribed is associated with an increase in macroscopic hematuria and macroscopic hematuria with clot retention after transurethral resection of the prostate. These findings emphasize the importance of nursing practice in both preoperative and postoperative care of patients undergoing surgery. Nurses need to be very vigilant in assessing patients at risk of increased bleeding from a transurethral resection of the prostate by examining their medication regimen.
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Egholm G, Thim T, Olesen K, Madsen M, Sorensen H, Jensen S, Jensen L, Botker H, Kristensen S, Maeng M. Dual anti-platelet therapy after coronary drug-eluting stent implantation and surgery-associated major adverse events. Thromb Haemost 2017; 116:172-80. [DOI: 10.1160/th15-12-0954] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/15/2016] [Indexed: 11/05/2022]
Abstract
SummarySurgery may necessitate interruption of dual antiplatelet therapy (DAPT) within the first year after coronary drug-eluting stent (DES) implantation. We conducted a population-based cohort study to assess the rate of surgery within the first year after DES implantation, surgery-associated major adverse cardiac events (MACE), reoperation for bleeding within 30 days after surgery, and two nested case-control analyses to explore any association between preoperative antiplatelet therapy, MACE, and reoperation for bleeding. In the cohort of 22,654 patients treated with DES, 1,944 patients (8.6 %) underwent moderate- to high-risk surgery within 12 months. Of these, 62 (3.2 %) experienced MACE and 54 (2.8 %) needed reoperation for bleeding within 30 days. In the nested case-control analyses of 458 cases and controls, where 70 % (n=324) had a first generation DES, absence of preoperative antiplatelet therapy was associated with an increased MACE rate (OR 2.36, 95 % CI 1.02–5.48) compared to single antiplatelet therapy (SAPT) or DAPT. Preoperative SAPT versus DAPT showed no difference in MACE rates (OR 0.85, 95 % CI 0.30–2.40). Surgery within the first month was associated with increased MACE rate (OR 4.67, 95 % CI 2.22–9.83) compared to surgery 2–12 months after DES implantation. Absence of preoperative antiplatelet therapy did not reduce reoperation for bleeding as compared to patients on SAPT or DAPT (OR 1.32, 95 % CI 0.56–3.12). In conclusion, absence of preoperative antiplatelet therapy and surgery within the first month after DES implantation were associated with increased MACE rates.
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Cheng HYHH, Cheung VYT. Patients on Long-Term Warfarin Undergo Gynecological Surgeries: A 10-Year Review of Perioperative Anticoagulation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 40:199-204. [PMID: 28821415 DOI: 10.1016/j.jogc.2017.05.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to review our experience with patients having gynaecological surgeries while on long-term anticoagulation and to postulate a better guide for their perioperative management. MATERIAL AND METHODS A retrospective review of all women on long-term warfarin who underwent gynaecological surgeries from January 2003 to December 2012. Data from medical records including operation reports and inpatient and outpatient charts were reviewed and analyzed. RESULTS Sixty-seven cases from 58 patients were identified. Twenty and 38 patients underwent major and minor gynaecological surgeries, respectively. The incidence of postoperative bleeding was higher after major surgery (4 cases, 20%) than after minor surgery (1 case, 2.1%; P = 0.025). All bleeding complications occurred between postoperative day 3 and day 10. Three patients, who had resumption of warfarin at a lower dose and slowly stepped up, had no bleeding complications. None of our patients developed venous thromboembolic complications. There was one mortality due to septic shock. CONCLUSION Patients on long-term anticoagulation have a trend of increased bleeding complications after major gynaecological surgeries than in minor gynaecological surgeries. We suggest that delaying resumption of warfarin at a lower dose may have a role in reducing the risk of postoperative bleeding without increasing the risk of venous thromboembolism.
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Affiliation(s)
| | - Vincent Y T Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, Hong Kong
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Yang C, Vadasz A, Szikora I. Treatment of ruptured blood blister aneurysms using primary flow-diverter stenting with considerations for adjunctive coiling: A single-centre experience and literature review. Interv Neuroradiol 2017; 23:465-476. [PMID: 28758550 DOI: 10.1177/1591019917720805] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective The objective of this article is to conduct a single-centre evaluation and quick literature review of the effectiveness of primary flow-diverter (FD) treatment of ruptured blood blister aneurysms (BBAs), with additional relevance of adjunctive coiling. Methods Patients presenting with subarachnoid haemorrhage (SAH) due to ruptured BBAs and subsequently treated with FDs were retrospectively selected from June 2010 to January 2017. Treatment techniques, angiographic data on occlusion rates and procedural success as well as clinical outcomes using the modified Rankin Scale (mRS) were collated. Cross-reference of results were made with available literature. Results Thirteen patients harbouring 14 BBAs were recruited. Of the 14 aneurysms, five (35.7%) showed immediate complete occlusion after the procedure (four of these five patients had adjunctive coiling). All of the aneurysms showed complete occlusion by the six- to nine-month control diagnostic angiogram. No rebleed or retreatment was experienced. Twelve of 13 (92%) patients had an mRS score of 0-1 at the last clinical follow-up. From the pooled data of the literature review, eventual aneurysm occlusion was achieved in 48/56 patients, with five patients requiring further endovascular treatment. In the clinical follow-up period, an mRS of 0-2 was recorded for 83.3% (45/54) of patients. Conclusion Endovascular reconstruction of BBAs using FD treatment is an effective method with good final clinical outcomes. Adjunctive use of coiling achieves higher incidence of immediate complete occlusion of BBAs.
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Affiliation(s)
- Cunli Yang
- Department of Neurointerventions, National Institute of Neurosciences, Budapest, Hungary
| | - Agnes Vadasz
- Department of Neurointerventions, National Institute of Neurosciences, Budapest, Hungary
| | - István Szikora
- Department of Neurointerventions, National Institute of Neurosciences, Budapest, Hungary
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Themistoklis T, Theodosia V, Konstantinos K, Georgios DI. Perioperative blood management strategies for patients undergoing total knee replacement: Where do we stand now? World J Orthop 2017; 8:441-454. [PMID: 28660135 PMCID: PMC5478486 DOI: 10.5312/wjo.v8.i6.441] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/20/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023] Open
Abstract
Total knee replacement (TKR) is one of the most common surgeries over the last decade. Patients undergoing TKR are at high risk for postoperative anemia and furthermore for allogeneic blood transfusions (ABT). Complications associated with ABT including chills, rigor, fever, dyspnea, light-headedness should be early recognized in order to lead to a better prognosis. Therefore, perioperative blood management program should be adopted with main aim to reduce the risk of blood transfusion while maximizing hemoglobin simultaneously. Many blood conservation strategies have been attempted including preoperative autologous blood donation, acute normovolemic haemodilution, autologous blood transfusion, intraoperative cell saver, drain clamping, pneumatic tourniquet application, and the use of tranexamic acid. For practical and clinical reasons we will try to classify these strategies in three main stages/pillars: Pre-operative optimization, intra-operative and post-operative protocols. The aim of this work is review the strategies currently in use and reports our experience regarding the perioperative blood management strategies in TKR.
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Yun JH, Jung HI, Lee HU, Baek MJ, Bae SH. The efficacy of laparoscopic cholecystectomy without discontinuation in patients on antithrombotic therapy. Ann Surg Treat Res 2017; 92:143-148. [PMID: 28289668 PMCID: PMC5344804 DOI: 10.4174/astr.2017.92.3.143] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/10/2016] [Accepted: 10/20/2016] [Indexed: 01/12/2023] Open
Abstract
Purpose Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgeries in the world today. However, there is no consensus regarding whether LC can be performed in patients with acute cholecystitis while on antithrombotic therapy. The objective of our study was to describe postoperative outcomes of patients who underwent emergent LC without interruption to antithrombotic therapy. Methods We performed a retrospective review of patients who underwent LC for acute cholecystitis while on antithrombotic therapy from 2010 to 2015 at Soonchunhyang Universtiy Cheonan Hospital. Patients were divided into 2 groups as underwent emergent LC and elective LC. Results A total of 67 patients (emergent group, 22; elective group, 45) were included in the analysis. Elective group had significantly longer duration between the admission and operation (8 [7–10] days vs. 2 [1–3] days, P < 0.001) and longer duration of antithrombotic drugs discontinuation (7 days vs. 1 [0–3] days, P < 0.001). Emergent group had significantly more postoperative anemia (6 patients vs. 0 patient, P = 0.001) and 3 of 6 patients received packed RBC transfusion in postoperative period. However, there was no significant difference in length of postoperative stays, length of intensive care unit stays and mortality rates. Conclusion Emergent LC without interruption to antithrombotic therapy was relatively safe and useful. A well-designed multicenter study is needed to confirm the safety and efficacy of LC without suspension of antithrombotic therapy and to provide a simple guideline.
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Affiliation(s)
- Jong Hyuk Yun
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hae Il Jung
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hyoung Uk Lee
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Moo-Jun Baek
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Sang Ho Bae
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Koenen W, Kunte C, Hartmann D, Breuninger H, Moehrle M, Bechara F, Schulze H, Lösler A, Löser C, Wetzig T, Pappai D, Rapprich S, Weiß C, Faulhaber J. Prospective multicentre cohort study on 9154 surgical procedures to assess the risk of postoperative bleeding - a DESSI study. J Eur Acad Dermatol Venereol 2017; 31:724-731. [DOI: 10.1111/jdv.14080] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 11/22/2016] [Indexed: 12/21/2022]
Affiliation(s)
- W. Koenen
- Department of Dermatology and Allergy; University Hospital Mannheim; Mannheim Germany
| | - C. Kunte
- Department of Dermatology and Allergy; University Hospital Munich (LMU); Munich Germany
| | - D. Hartmann
- Department of Dermatology and Allergy; University Hospital Munich (LMU); Munich Germany
| | - H. Breuninger
- Department of Dermatology; University Hospital Tübingen; Tübingen Germany
| | - M. Moehrle
- Department of Dermatology; University Hospital Tübingen; Tübingen Germany
| | - F.G. Bechara
- Department of Dermatology, Venereology and Allergology; Ruhr-University Bochum; Bochum Germany
| | - H.J. Schulze
- Department of Dermatology; Center for Skin Tumors; Münster-Hornheide; Münster Germany
| | - A. Lösler
- Department of Dermatology; Center for Skin Tumors; Münster-Hornheide; Münster Germany
| | - C.R. Löser
- Dermatology Hospital and Skin Tumor Center; Ludwigshafen Hospital; Ludwigshafen Germany
| | - T. Wetzig
- Department of Dermatology, Venereology and Allergology; University of Leipzig Medical Centre; Leipzig Germany
| | - D. Pappai
- Department of Dermatology; University Hospital Münster; Münster Germany
| | - S. Rapprich
- Department of Dermatology; Hospital of Darmstadt; Darmstadt Germany
| | - C. Weiß
- Department of Biostatistics; University Hospital Mannheim; Mannheim Germany
| | - J. Faulhaber
- Department of Dermatology and Allergy; University Hospital Mannheim; Mannheim Germany
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Abstract
STUDY DESIGN Cross-sectional, modified Delphi approach. OBJECTIVE The primary objective of this study was to identify patients at risk of increased perioperative blood loss according to the opinion of expert spine surgeons across Canada. The secondary objective was to obtain information about the experts' approach on how to minimize significant blood loss perioperatively. SUMMARY OF BACKGROUND DATA Significant blood loss in major spinal surgeries has been associated with increased intra- and perioperative complications and costs. The current available evidence regarding risk factors and preventive measures for increased blood loss remains incomplete. METHODS A modified Delphi approach was employed to generate consensus opinion on the risk factors and preventive measures for significant blood loss in major spinal surgeries. Twenty-five spine surgeons in Canada participated in this study. RESULTS Among various factors, surgery for the treatment of spine tumors and prolonged operative time of greater than 5 hours were found to be the most important predictive factors for blood loss in spine surgery. On the other hand, appropriate surgical hemostasis was considered the most effective measure for the prevention of blood loss in these surgeries. CONCLUSION We recommend the reduction of blood loss by means of meticulous hemostasis and shorter operative time when it is safe and possible. This might result in better treatment outcomes. It would also lead to a reduction in costs associated with major spine surgeries and would ultimately lead to greater value-based spine care. LEVEL OF EVIDENCE 4.
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Kil BT, Kim BI, Kim JH. Knot Formation at Removal of an Epidural Catheter Placed Against Insertion Resistance Encountered at the Entrance of the Epidural Space. KOSIN MEDICAL JOURNAL 2016. [DOI: 10.7180/kmj.2016.31.2.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Knotting of an epidural catheter occurs very rarely with an estimated incidence of 0.0015%. We present a case of an epidural catheter knot formed at removal of an epidural catheter following a forceful insertion of the catheter against resistance met at the entrance of the epidural space during threading of the catheter through Tuohy needle placed uneventfully in a 65 year-old male patient undergoing epidural anesthesia. During removal of the epidural catheter, significant resistance was encountered on traction and it was found that approximately 1.5 ㎝ portion of the catheter had been retained within the patient's subcutaneous tissue. Firm traction was employed to withdraw the catheter against the resistance. The catheter was pulled out uneventfully from the patient. A knot estimated to be formed during removal of the catheter was observed at 0.6 ㎝ proximal to the catheter tip. No complications and side effects were noted until the patient's discharge.
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Essandoh MK, Dalia AA, George BS, Flores AS, Otey AJ, Kirtane AJ, Broderick TM, Rao SV. CASE 11—2016 Perioperative Coronary Thrombosis in a Patient With Multiple Second-Generation Drug-Eluting Stents: Is It Time for a Paradigm Shift? J Cardiothorac Vasc Anesth 2016; 30:1698-1708. [DOI: 10.1053/j.jvca.2016.03.157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Indexed: 11/11/2022]
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Roslani AL, Jaafar AH, Ruhani AI. Non-ST Elevation Myocardial Infarction and Coronary Artery Stenting in Pregnancy in a Woman with Resistant Familial Hyperlipidaemia. J Obstet Gynaecol India 2016; 66:698-702. [PMID: 27803548 DOI: 10.1007/s13224-016-0878-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 03/19/2016] [Indexed: 11/25/2022] Open
Affiliation(s)
- Anna Liza Roslani
- Department of Obstetrics and Gynaecology, Hospital Tengku Ampuan Afzan, Jalan Tanah Putih, 25100 Kuantan, Pahang Malaysia
| | - Abdul Hadi Jaafar
- Department of Cardiology, Hospital Tengku Ampuan Afzan, Kuantan, Malaysia
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Ghantous AE, Ferneini EM. Aspirin, Plavix, and Other Antiplatelet Medications: What the Oral and Maxillofacial Surgeon Needs to Know. Oral Maxillofac Surg Clin North Am 2016; 28:497-506. [PMID: 27595478 DOI: 10.1016/j.coms.2016.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Most patients with coronary artery disease and peripheral vascular disease are on long-term antiplatelet therapy and dual therapy. Achieving a balance between ischemic and bleeding risk remains an important factor in managing patients on antiplatelet therapy. For most outpatient surgical procedures, maintenance and continuation of this therapy are recommended. Consultation with the patient's cardiologist, physician, and/or vascular surgeon is always recommended before interrupting or withholding this treatment modality.
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Affiliation(s)
- Andre E Ghantous
- Division of Cardiology, Department of Medicine, Yale University School of Medicine, 333 Cedar St., New Haven, CT 06510, USA
| | - Elie M Ferneini
- Private Practice, Greater Waterbury OMS, 435 Highland Avenue, Suite 100, Cheshire, CT 06410, USA; Beau Visage Med Spa, 435 Highland Avenue, Suite 100, Cheshire, CT 06410, USA; Division of Oral and Maxillofacial Surgery, Department of Craniofacial Sciences, University of Connecticut, 263 Farmington Avenue, Farmington, CT 06030, USA.
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A retrospective study showing the extent of compliance with perioperative guidelines in patients with coronary stents with regard to double antiplatelet therapy. J Clin Anesth 2016; 33:179-84. [PMID: 27555160 DOI: 10.1016/j.jclinane.2016.01.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 01/16/2016] [Accepted: 01/21/2016] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To evaluate perioperative dual antiplatelet therapy management in patients with previously placed coronary stents. DESIGN Retrospective medical record review. SETTING Academic medical center. PATIENTS A total of 1891 surgical cases performed at Vanderbilt University Medical Center in 2012 were evaluated using a perioperative database. Of these, 161 had complete data records that were evaluated using 2 evidence-based and expert opinion-supported protocols. INTERVENTIONS N/A. MEASUREMENTS This study is meant to evaluate perioperative antiplatelet management decisions in patients with coronary stents. MAIN RESULTS Management decisions were consistent with guidelines regarding antiplatelet therapy in 13% (21/161) of patients. Of the 87% (140/161) of cases where decisions were not consistent, 88% (123/140) were due to discontinuing aspirin preoperatively when there was not a high risk of surgical bleeding. CONCLUSIONS This study revealed suboptimal adherence to current perioperative antiplatelet management guidelines in patients with coronary stents. The lack of adherence to current guidelines is concerning and could be used to support the notion of an anesthesiologist-led Perioperative Surgical Home.
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Kamath AF, Pagnano MW. Blood Management for Patients Undergoing Total Joint Arthroplasty. JBJS Rev 2016; 1:01874474-201312000-00001. [PMID: 27490505 DOI: 10.2106/jbjs.rvw.m.00046] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Atul F Kamath
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Gonda 14, Rochester, MN 55905
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McCunniff PT, Young ES, Ahmadinia K, Kusin DJ, Ahn UM, Ahn NU. Chronic Antiplatelet Use Associated With Increased Blood Loss in Lumbar Spinal Surgery Despite Adherence to Protocols. Orthopedics 2016; 39:e695-700. [PMID: 27111080 DOI: 10.3928/01477447-20160419-04] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/10/2016] [Indexed: 02/03/2023]
Abstract
There are conflicting reports regarding postoperative bleeding risks associated with discontinuation of antiplatelet therapy at least 7 days preoperatively. Most of the studies in the spine literature are based on surveys or anecdotal evidence. The majority of surgeons discontinue therapy 7 days preoperatively, but this varies widely from 5 to 21 days. The purpose of this retrospective study was to assess whether chronic antiplatelet use is associated with increased intraoperative blood loss, need for transfusion, and perioperative complications. Of 454 patients who underwent elective lumbar spinal surgery, 85 were on antiplatelet therapy and 369 were not. All patients stopped antiplatelet therapy at least 7 days preoperatively with approval from their cardiologist or primary care provider. Multiple regression analysis was performed and corrected for age, sex, antiplatelet therapy, number of levels decompressed/fused/instrumented, preoperative hematocrit, and postoperative hematocrit. Results showed that preoperative antiplatelet therapy, despite at least 7 days of discontinuation, is a statistically significant predictor (P=.04) of increased intraoperative blood loss. Blood transfusion was not associated with antiplatelet use but was associated with the number of levels fused, age, and low preoperative hematocrit (all P<.01). There were no recorded complications in either group. The authors conclude that antiplatelet therapy is associated with an increased risk of intraoperative blood loss in spine patients despite discontinuation at least 7 days preoperatively, but the clinical significance of this is unclear given the lack of association with blood transfusions and perioperative complications. [Orthopedics. 2016; 39(4):e695-e700.].
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Mica L, Simmen H, Werner CML, Plecko M, Keller C, Wirth SH, Sprengel K. Fresh frozen plasma is permissive for systemic inflammatory response syndrome, infection, and sepsis in multiple-injured patients. Am J Emerg Med 2016; 34:1480-5. [PMID: 27260556 DOI: 10.1016/j.ajem.2016.04.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The correction of coagulopathy with fresh frozen plasma (FFP) is one of the main issues in the treatment of multiple-injured patients. Infectious and septic complications contribute to an adverse outcome in multiple-injured patients. Here, we investigated the role of FFP in the development of inflammatory complications given within the first 48 hours. METHODS A total of 2033 patients with multiple injuries and an Injury Severity Score greater than 16 points and aged 16 years or older were included. The population was subdivided into 2 groups: those who received FFP and those who did not. The data were analyzed using SPSS version 22.0. Associations between the data were tested using Pearson correlation. Independent predictivity was analyzed by binary logistic regression and multivariate regression. Data were considered as significant if P<.05. RESULTS The prothrombin time at admission was significantly lower (68.5%±23.3% vs 81.8%±21.0% normal; P<.001) in the group receiving FFP. The application of FFP led to a more severe systemic inflammatory response syndrome (SIRS) grade (3.0±1.2 vs 2.2±1.4; P<.001), to a higher infection rate (48% vs 28%; P<.001), and to a higher sepsis rate (29% vs 13%; P<.001) in the patients receiving FFP. The correlations between SIRS and the incidence of infections and sepsis increased with the amount of FFP applied (P<.001). CONCLUSIONS Treatment with FFP of bleeding patients with multiple injuries enhances the risk of SIRS, infection, and sepsis; however, a multifactorial genesis has to be postulated.
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Affiliation(s)
- Ladislav Mica
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland.
| | - Hanspeter Simmen
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | - Clément M L Werner
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | - Michael Plecko
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | | | | | - Kai Sprengel
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
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Mehta AY, Mohammed BM, Martin EJ, Brophy DF, Gailani D, Desai UR. Allosterism-based simultaneous, dual anticoagulant and antiplatelet action: allosteric inhibitor targeting the glycoprotein Ibα-binding and heparin-binding site of thrombin. J Thromb Haemost 2016; 14:828-38. [PMID: 26748875 PMCID: PMC4828251 DOI: 10.1111/jth.13254] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 12/24/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Allosteric inhibition is a promising approach for developing a new group of anticoagulants with potentially reduced bleeding consequences. Recently, we designed sulfated β-O4 lignin (SbO4L) as an allosteric inhibitor that targets exosite 2 of thrombin to reduce fibrinogen cleavage through allostery and compete with glycoprotein Ibα to reduce platelet activation. OBJECTIVE To assess: (i) the antithrombotic potential of a novel approach of simultaneous exosite 2-dependent allosteric inhibition of thrombin and competitive inhibition of platelet activation; and (ii) the promise of SbO4L as the first-in-class antithrombotic agent. METHODS A combination of whole blood thromboelastography, hemostasis analysis, mouse arterial thrombosis models and mouse tail bleeding studies were used to assess antithrombotic potential. RESULTS AND CONCLUSIONS SbO4L extended the clot initiation time, and reduced maximal clot strength, platelet contractile force, and the clot elastic modulus, suggesting dual anticoagulant and antiplatelet effects. These effects were comparable to those observed with enoxaparin. A dose of 1 mg of SbO4L per mouse prevented occlusion in 100% of arteries, and lower doses resulted in a proportionally reduced response. Likewise, the time to occlusion increased by ~ 70% with a 0.5-mg dose in the mouse Rose Bengal thrombosis model. Finally, tail bleeding studies demonstrated that SbO4L does not increase bleeding propensity. In comparison, a 0.3-mg dose of enoxaparin increased the bleeding time and blood volume loss. Overall, this study highlights the promise of the allosteric inhibition approach, and presents SbO4L as a novel anticoagulant with potentially reduced bleeding side effects.
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Affiliation(s)
- Akul Y. Mehta
- Department of Medicinal Chemistry and Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219, USA
| | - Bassem M. Mohammed
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA 23298, USA
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo 11562, Egypt
| | - Erika J. Martin
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Donald F. Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - David Gailani
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, Nashville, TN 37203
| | - Umesh R. Desai
- Department of Medicinal Chemistry and Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219, USA
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45
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Hiller KN. Clinically relevant exaggerated pharmacodynamic response to dual antiplatelet therapy detected by Thromboelastogram(®) Platelet Mapping™. J Anaesthesiol Clin Pharmacol 2016; 32:112-4. [PMID: 27006555 PMCID: PMC4784190 DOI: 10.4103/0970-9185.173347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) is the standard of care for primary and secondary prevention strategies in patients with coronary artery disease after stenting. Current guidelines recommend that DAPT be continued for 12 months in patients after receiving drug eluting stents. Approximately 5% of these patients will present within this 12-month period for noncardiac surgery. This case report describes a clinically relevant exaggerated pharmacodynamic response to DAPT detected by preoperative assessment of platelet function. Based on the clinical history and physical exam and subsequent lab results, a general anesthetic was performed rather than a spinal anesthetic and the surgical procedure was changed. An exaggerated pharmacodynamic response to DAPT poses its own set of risks (unexpected uncontrolled bleeding, epidural hematoma following neuraxial block placement) that point-of-care aggregation testing may decrease or mitigate by altering clinical decision making. If the clinical history and physical exam reveal possible platelet dysfunction in patients receiving DAPT, preoperative platelet function testing should be considered.
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Affiliation(s)
- Kenneth N Hiller
- Department of Anesthesiology, University of Texas Medical School at Houston, Houston, TX 77030, USA
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46
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Nenna A, Spadaccio C, Prestipino F, Lusini M, Sutherland FW, Beattie GW, Petitti T, Nappi F, Chello M. Effect of Preoperative Aspirin Replacement With Enoxaparin in Patients Undergoing Primary Isolated On-Pump Coronary Artery Bypass Grafting. Am J Cardiol 2016; 117:563-570. [PMID: 26721653 DOI: 10.1016/j.amjcard.2015.11.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/19/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
Management of preoperative antiplatelet therapy in coronary artery bypass grafting (CABG) is variable among surgeons: guidelines collide with prejudices because replacement of aspirin with low-molecular-weight heparin is still performed because of a presumed minor bleeding risk. This study aims to analyze postoperative bleedings and complications in patients scheduled for elective primary isolated on-pump CABG, depending on preoperative aspirin treatment or its replacement with enoxaparin. In this cohort study, we propensity score matched 200 patients in whom aspirin was stopped at least 5 days before CABG and replaced with enoxaparin and 200 patients who continued aspirin therapy until the day before surgery. Postoperative bleedings and complications were monitored during hospitalization. Among patients who continued aspirin treatment, mean overall bleeding was 701.0 ± 334.6 ml, whereas in the matched enoxaparin group, it was significantly greater (882.6 ± 64.6 ml, p value <0.001); this was associated with reduced postoperative complications, lower values of postoperative C-reactive protein in aspirin takers, and a presumed protective effect for statins. After propensity score adjustment, aspirin treatment carried a protective effect against major postoperative bleeding (odds ratio 0.312, p = 0.001). In conclusion, postoperative bleeding is reduced in patients who continued aspirin, likely due to a reduction in postoperative inflammation. The practice of empirically discontinuing aspirin and replacing it with enoxaparin before CABG should be abandoned. Patients with coronary artery disease referred to CABG should continue antiplatelet medications until the surgical procedure. Those results might be extended to patients under oral anticoagulant therapy requiring CABG.
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47
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Tanaka A, Ishii H, Tatami Y, Shibata Y, Osugi N, Ota T, Kawamura Y, Suzuki S, Nagao Y, Matsushita T, Murohara T. Unfractionated Heparin during the Interruption of Antiplatelet Therapy for Non-cardiac Surgery after Drug-eluting Stent Implantation. Intern Med 2016; 55:333-7. [PMID: 26875956 DOI: 10.2169/internalmedicine.55.5495] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Heparin is not recommended to be administered during the interruption of antiplatelet therapy for non-cardiac surgery. However, there are insufficient data to determine the value. The purpose of the present study was to evaluate the clinical results of the administration of unfractionated heparin during the interruption of antiplatelet therapy in non-cardiac surgery patients who had previously undergone drug-eluting stent (DES) implantation. METHODS We retrospectively identified 210 elective non-cardiac surgical procedures that were performed with the administration of unfractionated heparin during interruption of all antiplatelet therapies in patients who had previously undergone DES implantation. Heparin was administered during the perioperative period in accordance with the local practice guideline at out institution. We examined the clinical outcomes within 30 days of surgery. RESULTS The mean number of implanted DESs was 2.1±1.3. No major adverse cardiac events (including cardiac death, definite stent thrombosis, and non-fatal myocardial infarction) occurred in any of the 210 cases within 30 days of surgery. Four of the 210 cases (1.9%) required reoperation for bleeding within 30 days of surgery. CONCLUSION Our data showed the potential for the perioperative management with unfractionated heparin administration in Japanese patients who had previously undergone DES implantation who required non-cardiac surgery with the interruption of all antiplatelet therapies.
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Affiliation(s)
- Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
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48
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Yu WS, Jung HS, Lee JG, Kim DJ, Chung KY, Lee CY. Safety of thoracoscopic surgery for lung cancer without interruption of anti-platelet agents. J Thorac Dis 2015; 7:2024-32. [PMID: 26716042 DOI: 10.3978/j.issn.2072-1439.2015.11.40] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Perioperative bleeding concerns have led to the general recommendation that antiplatelet agents (APAs) be discontinued 7-10 days preoperatively, but this could increase the risk of perioperative cardiovascular events. This retrospective study aimed to evaluate the safety of APA continuation during thoracoscopic surgery for lung cancer. METHODS Between January 2009 and February 2015, 164 patients taking APAs underwent curative resection. Comparisons were conducted between two groups: preoperatively interrupted APA administration (group I, n=106) and continued APA administration (group N, n=58). RESULTS Group N had a significantly higher revised cardiac risk index (rCRI) (P=0.001). Lobectomy was performed in the majority of patients [95 (89.6%) in group I; 52 (89.7%) in group N]. There were no significant differences in intraoperative outcomes, such as the thoracotomy conversion rate, operating time, intraoperative transfusion, and amount of blood loss during the operation, or postoperative outcomes, such as postoperative bleeding and thrombotic complications, postoperative transfusions, and operative mortality. Within group N, the patients taking aspirin + clopidogrel (n=11) had significantly greater postoperative bleeding (P=0.005), and more postoperative transfusions (P=0.003) and chest tube drainage over a 3-day period (P=0.049) compared with other antiplatelet regimens. CONCLUSIONS Continued use of APAs during thoracoscopic surgery for lung cancer could be safely done in patients at high risk of cardiac or thrombotic events. However, in patients administered aspirin + clopidogrel, it may be the best to continue aspirin only because of an increased risk of postoperative bleeding and transfusion requirements.
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Affiliation(s)
- Woo Sik Yu
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Suk Jung
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Gu Lee
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae Joon Kim
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung Young Chung
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chang Young Lee
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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Sa-ngasoongsong P, Kulachote N, Sirisreetreerux N, Chanplakorn P, Laohajaroensombat S, Pinsiranon N, Woratanarat P, Kawinwonggowit V, Suphachatwong C, Wajanavisit W. Effect of early surgery in high surgical risk geriatric patients with femoral neck fracture and taking antiplatelet agents. World J Orthop 2015; 6:970-976. [PMID: 26716093 PMCID: PMC4686444 DOI: 10.5312/wjo.v6.i11.970] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 09/30/2015] [Accepted: 10/27/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of early surgical intervention on the high surgical risk elderly patients who sustained femoral neck fracture (FNF) and taking concomitant antiplatelet agents.
METHODS: Between 2010 and 2012, a prospective study was conducted on 49 geriatric patients, who took antiplatelet agents, sustained FNF and underwent surgery within 72 h [early surgery (ES) group], and these were compared with a retrospective consecutive case series of patients with similar characteristics (45 cases) who had delayed surgery (DS group) after 72 h during an earlier 3-year period. Postoperative outcomes were followed for one year and compared.
RESULTS: There were non-significant differences in perioperative blood loss, blood transfusion, intensive care unit requirement and postoperative mortality (P > 0.05 all). There were 2 patients (4%) in the DS group who died after surgery (P = 0.23). However, the ES group showed a significantly better postoperative outcome in terms of postoperative complications, length of hospital stay, and functional outcome (P < 0.05 all).
CONCLUSION: Early hip surgery in geriatric hip fracture patients with ongoing antiplatelet treatment was not associated with a significant increase of perioperative blood loss and postoperative mortality. Moreover, ES resulted in a better postoperative surgical outcome. In early hip surgery protocol, the antiplatelet agents are discontinued and the patient is operated on within 72 h after admission, which is safe and effective for the medically fit patients.
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50
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Vela Vásquez R, Peláez Romero R. Aspirin and spinal haematoma after neuraxial anaesthesia: Myth or reality? Br J Anaesth 2015; 115:688-98. [DOI: 10.1093/bja/aev348] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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