Safety of lumbar puncture for people who are treated with ADP receptor antagonists

BACKGROUND

Current guidelines state that clopidogrel and other adenosine-diphosphate receptor antagonists (ADPra) should be stopped for at least 7 days before lumbar puncture (LP). This practice may delay the diagnosis of treatable neurological emergencies and may increase the risk of cardiovascular morbidity due to withholding antiplatelets. We aimed to summarize all cases under our care, in which LP was performed without discontinued ADPra.

METHODS

A retrospective case series study of all patients who underwent LP without interruption of ADPRa or with treatment interruption that was shorter than 7 days. Medical records were searched for documented complications. Traumatic tap was defined as cerebrospinal fluid red cell count ≥ 1000 cell/μL. Incidence of traumatic tap among people who underwent LP under ADPRa was compared to traumatic tap incidence in two control groups: LP under aspirin and LP without any anti-platelet.

RESULTS

159 patients underwent LP under ADPRa [Age: 68.4 ± 12.1, Female: 63 (40%), 81 (51%) were treated with both aspirin and ADPRa]. 116 procedures were carried out without any interruption of ADPRa. In the other 43, the median delay between treatment interruption and the procedure was 2 days (range: 1-6 days). Incidence of traumatic tap was 8/159 (5%), 9/159 (5.7%) and 4/160 (2.5%) among those who underwent LP under ADPRa, under aspirin and without any anti-platelet, respectively. [X²(2) = 2.13, P = 0.35)]. No patient developed spinal hematoma or any neurological deficit.

CONCLUSIONS

Lumbar puncture without discontinuation of ADP receptor antagonists seems safe. Similar case series may ultimately lead to guidelines change.

Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines

BACKGROUND

Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia.

DESIGN

A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline.

RESULTS

Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%.

DISCUSSION

Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply.

CONCLUSION

In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.

[SBA 2020: Regional anesthesia guideline for using anticoagulants update]

The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology (SBA) 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative revision, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.

Safety of Lumbar Puncture Performed on Dual Antiplatelet Therapy

Practice guidelines generally recommend delaying lumbar puncture (LP) in patients on dual antiplatelet therapy, with these recommendations often citing an increased risk of hemorrhagic complications, specifically the development of epidural hematomas. However, no data exist about the risks of performing an LP in the setting of dual antiplatelet therapy and conclusions are often based on data from spinal anesthesia literature. We reviewed the medical records of 100 patients who underwent LP while taking dual antiplatelet therapy. We recorded the number of traumatic and bloody cerebrospinal fluid results as well as the presence of any complications occurring within 3 months of the procedure. Complications requiring imaging or hospitalization were considered serious. The most common complication was back pain, which was reported by 2 patients, only 1 of which was ultimately found to be attributable to the procedure. No serious complications occurred. Cerebrospinal fluid analysis was consistent with a traumatic LP, defined as having at least 100 red blood cells per microliter, in 8% of cases. Bloody LP, defined as having 1000 red blood cells per microliter, occurred in 4% of cases. The percentage of traumatic or bloody LPs was within the range reported previously for LPs performed in any setting. Although this is a small study and additional review is necessary, performing LPs in the setting of dual antiplatelet therapy may not pose an increased risk of serious complications.

Neuraxial anaesthesia in parturient with cardiac disease

Parturient with corrected or uncorrected cardiac problem may undergo neuraxial anaesthesia for several reasons and in different trimesters. The altered physiological state in a parturient is further deranged in the presence of a cardiovascular lesion, producing the added risk to the parturient undergoing a neuraxial block. A detailed evaluation, knowledge regarding cardiovascular disease state, more vigilant monitoring, and a team approach can lead to a successful outcome.

Lumbar puncture in patients using anticoagulants and antiplatelet agents

The use of anticoagulants and antiplatelet agents has largely increased. Diagnostic lumbar puncture in patients taking these drugs represents a challenge considering the opposing risks of bleeding and thrombotic complications. To date there are no controlled trials, specific guidelines, nor clear recommendations in this area. In the present review we make some recommendations about lumbar puncture in patients using these drugs. Our recommendations take into consideration the pharmacology of these drugs, the thrombotic risk according to the underlying disease, and the urgency in cerebrospinal fluid analysis. Evaluating such information and a rigorous monitoring of neurological symptoms after lumbar puncture are crucial to minimize the risk of hemorrhage associated neurological deficits. An individualized patient decision-making and an effective communication between the assistant physician and the responsible for conducting the lumbar puncture are essential to minimize potential risks.

Decision making on timing of surgery for hip fracture patients on clopidogrel

Patients taking clopidogrel who sustain a fractured neck of femur pose a challenge to orthopaedic surgeons. The aim of this study was to determine whether delay to theatre for these patients affects drop in haemoglobin levels, need for blood transfusion, length of hospital stay and 30-day mortality. A retrospective review of all neck of femur patients admitted at two centres in the North East of England over 3 years revealed 85 patients. Patients were divided into two groups depending on whether they were taking clopidogrel alone (C) or with aspirin (CA). Haemoglobin drop was significantly different in the CA group that was operated on early (CA1) versus the group for which surgery was delayed by over 48 hours (CA2): 3.3g/dl and 1.9g/dl respectively (p=0.01). The mean inpatient stay in group C was 35.9 days while in group CA it was 19.9 days (p=0.002). The mean length of stay in group CA2 (26.7 days) was significantly longer than for CA1 patients (14.1 days) (p=0.01). There were no significant differences in mortality or wound complications. Hip fracture patients on clopidogrel can be safely operated on early provided they are medically stable. Bleeding risk should be borne in mind in those patients on dual therapy with aspirin.

Is early hip fracture surgery safe for patients on clopidogrel? Systematic review, meta-analysis and meta-regression

INTRODUCTION

Hip fracture is a common presentation in the elderly population, many of whom will be taking the antiplatelet clopidogrel, which has the potential to increase perioperative bleeding. The aim of this systematic review and meta-analysis was to answer the questions: (1) is early hip fracture surgery for patients on clopidogrel associated with worse postoperative outcomes compared to patients not on clopidogrel? (2) is early versus delayed surgery for these patients associated with worse postoperative outcomes?

METHODS

A systematic search was conducted of MEDLINE, EMBASE, Cinahl and AMED databases. Results from patients undergoing early surgery on clopidogrel were compared to a control group not taking clopidogrel. In addition, patients taking clopidogrel undergoing early and delayed surgery were compared.

RESULTS

For patients taking clopidogrel undergoing early surgery, there was no associated increase in overall mortality (OR 0.89; 95% CI: 0.58-1.38) or 30-day mortality (OR 1.10 95% CI: 0.48-2.54). However, there was an associated increase in blood transfusion (OR 1.41 95% CI: 1.00-1.99). There was an associated decreased length of stay in the early surgery versus delayed surgery group (weighted mean difference -7.09 days (95% CI: -10.14 to -4.04).

DISCUSSION

Early surgery appears safe for patients with hip fracture though there may be a small increase in the rate of blood transfusion. However, larger prospective trials are required to confirm these findings.

Clopidogrel has no effect on mortality from hip fracture

Over 76,000 patients in the UK sustain a proximal femoral fracture. Clopidogrel is currently the world's second best selling drug. There has been much recent controversy surrounding the optimal time for surgical intervention in this medically challenging group of patients. This consecutive series of 1225 patients from our unit over six years included thirty patients concurrently taking clopidogrel whilst sustaining a hip fracture. Our study demonstrated no significant difference in ASA grade, intra-operative blood loss or subsequent transfusion, post-operative wound complication, or mortality to one year in those taking clopidogrel. The authors therefore advocate timely surgical intervention as rapidly as circumstances allow.

Antiplatelet therapy in patients with coronary artery stents for noncardiac surgery: Role of thromboelastography

The perioperative course of the patients who have undergone coronary stent placement was studied. These patients were on dual antiplatelet therapy and were posted for noncardiac surgery. Clopidogrel had been discontinued for a variable duration before noncardiac surgery. Thromboelastography (TEG) was performed preoperatively to assess their fitness for surgery. The surgery and the postoperative period were uneventful in all the patients. There was no incidence of increased bleeding in any of the patients. Blood transfusion was not required in any patient. We concluded that standard TEG can be used when in dilemma about the fitness of the patient for surgery. Although there are clear guidelines about the patients who are on dual antiplatelet therapy, in clinical practice, it is important to weigh the risk-benefit to the advantage of the patient. If we stop the dual antiplatelet therapy in a patient with drug eluting stent within 1 year of implantation, the risk of major adverse cardiac event increases many fold. If we continue clopidogrel and aspirin during surgery, the risk of bleeding increases but is not life-threatening, except when surgery is performed in closed spaces. Thus, to continue dual antiplatelet medication intraoperatively is better than to stop it. If the medicine has to be withheld, it should be withheld for the minimal possible duration and a TEG should be performed.

Risks and benefits of thoracic epidural anaesthesia

Thoracic epidural anaesthesia (TEA) reduces cardiac and splanchnic sympathetic activity and thereby influences perioperative function of vital organ systems. A recent meta-analysis suggested that TEA decreased postoperative cardiac morbidity and mortality. TEA appears to ameliorate gut injury in major surgery as long as the systemic haemodynamic effects of TEA are adequately controlled. The functional benefit in fast-track and laparoscopic surgery needs to be clarified. Better pain control with TEA is established in a wide range of surgical procedures. In a setting of advanced surgical techniques, fast-track regimens and a low overall event rate, the number needed to treat to prevent one death by TEA is high. The risk of harm by TEA is even lower, and other methods used to control perioperative pain and stress response also carry specific risks. To optimize the risk-benefit balance of TEA, safe time intervals regarding the use of concomitant anticoagulants and consideration of reduced renal function impairing their elimination must be observed. Infection is a rare complication and is associated with better prognosis. Close monitoring and a predefined algorithm for the diagnosis and treatment of spinal compression or infection are crucial to ensure patient safety with TEA. The risk-benefit balance of analgesia by TEA is favourable and should foster clinical use.

Management of patients with recently implanted coronary stents on dual antiplatelet therapy who need to undergo major surgery

About 5% of patients undergoing coronary stenting need to undergo surgery within the next year. The risk of perioperative cardiac ischemic events, particularly stent thrombosis (ST), is high in these patients, because surgery has a prothrombotic effect and antiplatelet therapy is often withdrawn in order to avoid bleeding. The clinical and angiographic predictors of ST are well known, and the proximity to an acute coronary syndrome adds to the risk. The current guidelines recommend delaying non-urgent surgery for at least 6 weeks after the placement of a bare metal stent and for 6-12 months after the placement of a drug-eluting stent, when the risk of ST is reduced. However, in the absence of formal evidence, these recommendations provide little support with regard to managing urgent operations. When surgery cannot be postponed, stratifying the risk of surgical bleeding and cardiac ischemic events is crucial in order to manage perioperative antiplatelet therapy in individual cases. Dual antiplatelet therapy should not be withdrawn for minor surgery or most gastrointestinal endoscopic procedures. Aspirin can be safely continued perioperatively in the case of most major surgery, and provides coronary protection. In the case of interventions at high risk for both bleeding and ischemic events, when clopidogrel withdrawal is required in order to reduce perioperative bleeding, perioperative treatment with the short-acting intravenous glycoprotein IIb-IIIa inhibitor tirofiban is safe in terms of bleeding, and provides strong antithrombotic protection. Such surgical interventions should be performed at hospitals capable of performing an immediate percutaneous coronary intervention at any time in the case of acute myocardial ischemia.

Perioperative management of clopidogrel therapy: the effects on in-hospital cardiac morbidity in older patients with hip fractures

BACKGROUND

Increasing numbers of older patients prescribed clopidogrel are presenting for urgent hip fracture surgery. Best practice for the management of clopidogrel therapy is unknown, although delays to surgery are associated with increased mortality. We investigated the influence of perioperative management of clopidogrel therapy on in-hospital cardiac morbidity and transfusion in this population.

METHODS

Retrospective review of all patients aged >60 yr, admitted to a single centre with hip fractures between June 2005 and November 2008. Acute coronary syndrome (ACS) was defined as a raised plasma troponin concentration >0.04 µg litre(-1) associated with chest pain, new ECG changes, or both.

RESULTS

Of 1381 patients admitted with hip fractures, 114 were receiving regular clopidogrel therapy with a median age of 83.7 (60-98) yr. Clopidogrel was withheld perioperatively in 111 (98%) of these patients. Twenty-three patients (20.2%) suffered an ACS. Risk peaked for ACS [odds ratio (OR) 6.7 (95% confidence interval, CI, 1.7-25.8)] (P=0.006) between days 4 and 8 after clopidogrel withdrawal. The OR for requiring a blood transfusion during or after surgery peaked at day 1 after clopidogrel withdrawal [OR 2.31 (95% CI, 1.02-5.21)] (P=0.044).

CONCLUSIONS

The length of withdrawal of clopidogrel therapy perioperatively was associated with a significantly increased incidence of ACS. An association between shorter withdrawal and increased blood transfusion requirements was also seen. The study emphasizes the cardiovascular risks of routinely interrupting clopidogrel therapy in this at-risk population and that a more considered, individualized, evidenced-based approach is needed.

Safety and Efficacy of Clopidogrel before Surgery

Clopidogrel is an antiplatelet drug that is used in patients who have had previous cerebrovascular events, acute coronary syndromes, or who underwent percutaneous coronary interventions (PCI) with bare metal or drug-eluting stents. About 5% of patients who undergo PCI have to undergo non-cardiac surgery within 1 year of coronary stent implantation. Patients who receive clopidogrel may be at increased risk of bleeding complications during surgery. The risk of coronary thrombosis after non-cardiac surgery increases, especially when surgery is performed early after stenting, and particularly when antiplatelet agents are withdrawn before surgery. The decision to continue or withhold clopidogrel should reflect a balance of the consequences of perioperative hemorrhage versus the risk of perioperative vascular complications. Close communication among surgeons, anesthesiologists, and cardiologist is necessary to minimize both adverse cardiac risk and surgical risk in those patients.

Progress in platelet medicine: focus on stent thrombosis and drug resistance

The outcome importance of coronary stent thrombosis has mandated the careful management of these devices and their associated platelet blockade during the perioperative period. Recent trials have highlighted the catastrophic outcomes after stent thrombosis. The maintenance of clinically effective platelet blockade not only is essential to prevent stent thrombosis but also to optimize outcome in the integrated management of acute coronary syndromes. Dual antiplatelet blockade with aspirin and clopidogrel must balance the risks of ischemia and bleeding in patients with acute coronary syndromes, especially in the subset who require urgent surgical coronary revascularization. Platelet resistance to thienopyridines such as clopidogrel and prasugrel may be a significant risk factor for adverse cardiovascular outcomes. This phenomenon is detectable by point-of-care assays although standardized definitions and standardized testing batteries have yet to be formulated. The determinants of platelet resistance to thienopyridine therapy include genetic polymorphisms (especially related to hepatic drug metabolism) and drug interactions (especially the proton pump inhibitors). Novel platelet blockers are currently in late clinical development and will likely induce more consistent platelet blockade because of pharmacokinetic advantages including the lack of hepatic metabolism for activation. These agents will likely supersede clopidogrel and prasugrel if randomized trials show superior efficacy and clinical safety.