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Coccolini F, Shander A, Ceresoli M, Moore E, Tian B, Parini D, Sartelli M, Sakakushev B, Doklestich K, Abu-Zidan F, Horer T, Shelat V, Hardcastle T, Bignami E, Kirkpatrick A, Weber D, Kryvoruchko I, Leppaniemi A, Tan E, Kessel B, Isik A, Cremonini C, Forfori F, Ghiadoni L, Chiarugi M, Ball C, Ottolino P, Hecker A, Mariani D, Melai E, Malbrain M, Agostini V, Podda M, Picetti E, Kluger Y, Rizoli S, Litvin A, Maier R, Beka SG, De Simone B, Bala M, Perez AM, Ordonez C, Bodnaruk Z, Cui Y, Calatayud AP, de Angelis N, Amico F, Pikoulis E, Damaskos D, Coimbra R, Chirica M, Biffl WL, Catena F. Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper. World J Emerg Surg 2024; 19:26. [PMID: 39010099 PMCID: PMC11251377 DOI: 10.1186/s13017-024-00554-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/01/2024] [Indexed: 07/17/2024] Open
Abstract
Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy.
| | - Aryeh Shander
- Anesthesiology and Critical Care, Rutgers University, Newark, NJ, USA
| | - Marco Ceresoli
- General Emergency and Trauma Surgery Department, Monza University Hospital, Monza, Italy
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado, Denver, CO, USA
| | - Brian Tian
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
| | - Dario Parini
- General Surgery Department, Rovigo Hospital, Rovigo, Italy
| | | | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Medical University, Plovdiv, Bulgaria
| | - Krstina Doklestich
- Clinic of Emergency Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Fikri Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Tal Horer
- Vascular and Trauma Surgery, Orebro Hospital, Orebro, Sweden
| | - Vishal Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Timothy Hardcastle
- Department of Trauma and Burns, Inkosi Albert Luthuli Central Hospital and Department of Surgical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Elena Bignami
- Anesthesia Department, Parma University Hospital, Parma, Italy
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, AB, Canada
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Igor Kryvoruchko
- Department of Surgery No. 2, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Ari Leppaniemi
- General Surgery Department, Melahiti Hospital, Helsinki, Finland
| | - Edward Tan
- Emergency Surgery Department, Radboud Medical Centre, Nijmegen, The Netherlands
| | - Boris Kessel
- Hillel Yaffe Medical Center, Rappaport Medical School, Haifa, Israel
| | - Arda Isik
- Division of General Surgery, School of Medicine, Istanbul Medeniyet University, Kadikoy, Istanbul, Turkey
| | - Camilla Cremonini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | | | - Lorenzo Ghiadoni
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
| | - Massimo Chiarugi
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | - Chad Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Pablo Ottolino
- Unidad de Trauma y Urgencias, Hospital Dr. Sótero del Río, Santiago de Chile, Chile
| | - Andreas Hecker
- Department of General, Thoracic and Transplant Surgery, University Hospital of Giessen, Giessen, Germany
| | - Diego Mariani
- General Surgery Department, Legnano Hospital, Legnano, Italy
| | - Ettore Melai
- ICU Department, Pisa University Hospital, Pisa, Italy
| | - Manu Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Vanessa Agostini
- Medicina Trasfusionale, IRCCS-Ospedale Policlinico San Martino, Genoa, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Yoram Kluger
- General, Emergency and Trauma Surgery Department, Rambam Medical Centre, Tel Aviv, Israel
| | | | - Andrey Litvin
- Department of Surgical Diseases No. 3, University Clinic, Gomel State Medical University, Gomel, Belarus
| | - Ron Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | | | - Belinda De Simone
- Department of Digestive and Emergency Surgery, Infermi Hospital, Rimini, Italy
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Aleix Martinez Perez
- Faculty of Health Sciences, Valencian International University (VIU), Valencia, Spain
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Zenon Bodnaruk
- Hospital Information Services for Jehovah's Witnesses, Tuxedo Park, NY, USA
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | | | - Nicola de Angelis
- General Surgery Department, Ferrara University Hospital, Ferrara, Italy
| | - Francesco Amico
- Discipline of Surgery, The University of Newcastle, Newcastle, Australia
| | - Emmanouil Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Raul Coimbra
- General Surgery Department, Riverside University Health System Medical Center, Loma Linda, CA, USA
| | - Mircea Chirica
- General Surgery Department, Grenoble University Hospital, Grenoble, France
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
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Gyi R, Cho BC, Hensley NB. Patient Blood Management in Vascular Surgery. Anesthesiol Clin 2022; 40:605-625. [PMID: 36328618 DOI: 10.1016/j.anclin.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.
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Affiliation(s)
- Richard Gyi
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Brian C Cho
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA; Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Nadia B Hensley
- Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA.
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Postoperative Thromboembolism According to the Type of Surgery: A Nationwide Study in the Republic of Korea. J Clin Med 2022; 11:jcm11061477. [PMID: 35329803 PMCID: PMC8948856 DOI: 10.3390/jcm11061477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 02/28/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022] Open
Abstract
Postoperative thromboembolism (TE) is a serious, but preventable, complication in surgical patients. Orthopedic surgery, neurosurgery, and vascular surgery are considered high risk for TE, and current guidelines recommend TE prophylaxis. However, insufficient data exist regarding TE risk in other general surgeries. This study identified the actual incidence and relative risk of postoperative TE in the real world, according to surgery type. Twenty-six surgeries between 1 December 2017 and 31 August 2019 were selected from the Health Insurance Review and Assessment Service database and analyzed for postoperative TE events. Among all patients, 2.17% had a TE event within 6 months of surgery and 0.75% had a TE event owing to anticoagulant treatment. The incidence of total TE events was the highest in total knee replacement (12.77%), hip replacement (11.46%), and spine surgery (5.98%). The incidence of TE with anticoagulant treatment was the highest in total knee replacement (7.40%), hip replacement (7.20%), and coronary artery bypass graft (CABG) surgery (3.81%). Hip replacement, total knee replacement, CABG surgery, spine surgery, and cardiac surgery except CABG surgery, showed relatively higher risks for total claimed venous TE. The relative risk of venous TE with anticoagulant treatment was the highest for hysterectomy, partial hepatectomy, hip replacement, cardiac surgery except CABG surgery, and total knee replacement. The relative risk of arterial TE was the highest for cardiac surgery, total knee replacement, and hip replacement. In the real world, the incidence of postoperative TE events from total knee replacement and those from hip replacement remain high, and some surgeries could have a relatively higher risk of TE than other surgeries. For patients undergoing these surgeries, studies to reduce the incidence of postoperative TE in clinical practice should be conducted.
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Nie Z, Ma W, Hu J. Models to predict the probability for intraoperative RBC transfusion during lumbar spinal stenosis and femoral fracture surgeries in aged patients. Transfus Apher Sci 2021; 60:103277. [PMID: 34563458 DOI: 10.1016/j.transci.2021.103277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/06/2021] [Accepted: 09/09/2021] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The goal of this study was to predict the probability of transfusion of red blood cells and the volume of blood consumption based on the clinical characteristics of patients before surgery. METHODS The medical records of 565 patients over 65 years old who underwent posterior lumbar surgery and 586 patients over 65 years old receiving femoral fracture surgery were reviewed. The clinical characteristics of the patients were subjected to multivariate regression analysis. The scores of these factors' influences on intraoperative red blood cells infusion were based on the odds ratio of each multivariate risk factor. Non-linear regression was performed to predict the probability of intraoperative blood transfusion and the volume of blood used for patients with different scores. RESULTS The factors that significantly influenced blood use during lumbar spinal stenosis and femoral fracture surgery in aged patients(P < 0.05) included age, body mass index, abnormal coagulation function, preoperative hemoglobin, administration of antithrombotic drugs, multisegmental lesions of the lumbar spine, femoral shaft fracture, secondary lumbar surgery and the time from fracture to surgery exceeding 48 h. According to our risk scoring system, patients of posterior lumbar surgery scored 0-10 and patients of femoral fracture had a score of 0-12. More than 50 % of patients receiving an intraoperative red blood cells transfusion during surgery scored>1. CONCLUSION The scoring system can be used as a predictive model for the probability of red blood cells transfusion and the blood volume in aged patients undergoing lumbar spinal stenosis and femoral fracture surgeries.
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Affiliation(s)
- Zhiyang Nie
- Transfusion Department, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, China.
| | - Wanru Ma
- Transfusion Department, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, China.
| | - Junhua Hu
- Transfusion Department, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, China.
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Louison S, Gabrielle P, Soudry A, Meillon C, Blanc J, Béal G, Arsène S, Le Mer Y, Berrod J, Kodjikian L, Creuzot‐Garcher C. Perioperative risk of bleeding with antithrombotic agents in macular surgery: a national, prospective, multicentre study. Acta Ophthalmol 2020; 98:e991-e997. [PMID: 32279459 DOI: 10.1111/aos.14434] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/15/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE To compare the risk of haemorrhagic complications in elective macular surgery between patients with no antithrombotic (AT) treatment (defined as patients with no history of AT therapy or who discontinued AT therapy) and patients who continued AT treatment during the surgery. METHODS E-case report forms were prospectively recorded in a database before vitreoretinal surgery and 1 month after. Data on patient characteristics, surgical techniques, haemorrhagic complications and antithrombotic status were collected. Patients with retinal detachment, proliferative diabetic retinopathy and previous retinal haemorrhage were excluded. RESULTS A total of 748 procedures (single procedure in one eye per patient) were performed between January and May 2019. Among them, 202 patients (27.0%) were treated with antithrombotic therapy at the time of surgery: 19.5% with antiplatelet agents (n = 146), 6.3% with anticoagulants (n = 47) including 3.2% (n = 24) patients treated with novel oral anticoagulants, 0.8% (n = 6) with anticoagulants and antiplatelet agents, and 0.4% (n = 3) with heparin. Overall, 92 patients (12.3%) developed one or more haemorrhagic complications, of which 63 (11.5%) and 29 (14.4%) were in the non-AT and AT group, respectively. The multivariate logistic regression model showed no difference between AT treatment groups regarding ocular bleeding complications (odds ratio [OR] 1.2, 95% confidence interval (CI) [0.7-2.2], p = 0.54). CONCLUSION No cases of uncontrolled or severe perioperative haemorrhage in patients continuing antithrombotic agents were reported in this selected population. For the majority of the patients taking antiplatelets or anticoagulants, these agents could be safely continued during macular surgery.
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Affiliation(s)
- Solenne Louison
- Department of Ophthalmology University Hospital Dijon France
| | - Pierre‐Henry Gabrielle
- Department of Ophthalmology University Hospital Dijon France
- Eye and Nutrition Research Group National Scientific Research Council (CNRS) National Institute of Agronomic Research (INRA) University of Burgundy Dijon France
| | - Agnès Soudry
- Department of Clinical Research and Investigation University Hospital Dijon France
| | - Cyril Meillon
- Department of Ophthalmology University Hospital Dijon France
| | - Julie Blanc
- Department of Ophthalmology University Hospital Dijon France
| | - Guillaume Béal
- Department of Anaesthesiology University Hospital Dijon France
| | - Sophie Arsène
- Department of Ophthalmology University Hospital Tours France
| | - Yannick Le Mer
- Department of Ophthalmology Rothschild Ophthalmologic Foundation Paris France
| | | | - Laurent Kodjikian
- Department of Ophthalmology Croix‐Rousse University Hospital Lyon France
| | - Catherine Creuzot‐Garcher
- Department of Ophthalmology University Hospital Dijon France
- Eye and Nutrition Research Group National Scientific Research Council (CNRS) National Institute of Agronomic Research (INRA) University of Burgundy Dijon France
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6
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Ashkenazi I, Schermann H, Gold A, Gurel R, Chechik O, Warschawski Y, Schwarzkopf R, Snir N. Is continuation of anti-platelet treatment safe for elective total hip arthroplasty patients? Arch Orthop Trauma Surg 2020; 140:2101-2107. [PMID: 33040197 DOI: 10.1007/s00402-020-03629-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/30/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Acetylsalicylic acid (aspirin) is a commonly prescribed medication, especially in the age group of individuals who undergo elective total hip arthroplasty (THA). Preoperative discontinuation of aspirin is believed to reduce intraoperative bleeding and other complications, but it may increase the risk of perioperative cardiovascular events. In this study we have sought to evaluate the safety of continuous aspirin treatment in patients undergoing elective THA. MATERIALS AND METHODS This is a retrospective analysis of a consecutive cohort who underwent elective THA in a tertiary medical center between 2011 and 2018. The cohort was divided into two groups-one that received continuous preoperative aspirin treatment and one that did not. Blood loss, peri- and postoperative complications, readmissions, and short- and long-term mortality were compared between groups. RESULTS Out of 757 consecutive patients (293 males, 464 females) who underwent elective primary THA, 552 were in the "non-aspirin" group and 205 were in the "aspirin" group and were not treated preoperative with other medication affecting hemostasis. Perioperative continuation of aspirin treatment did not significantly increase perioperative bleeding, as indicated by changes in hemoglobin levels (P = 0.72). There were no significant differences in short- and long-term mortality (P = 0.47 and P = 0.4, respectively) or other perioperative complications, such as readmission (P = 0.78), deep or superficial infection (P = 1 and P = 0.47, respectively), and cardiovascular events (none in both groups). CONCLUSION Peri-operative continuation of aspirin treatment in patients undergoing elective primary THA did not increase perioperative complications or mortality compared to the non-aspirin-treated patients. The protective effects of aspirin from postoperative thrombotic and cardiovascular events are well documented. The current findings dispute the need to preoperatively withhold aspirin treatment in patients undergoing elective primary THA.
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Affiliation(s)
- Itay Ashkenazi
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
| | - Haggai Schermann
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Aviram Gold
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ron Gurel
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ofir Chechik
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yaniv Warschawski
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ran Schwarzkopf
- Hospital for Joint Diseases, NYU Langone Orthopedic Hospital, New York, USA
| | - Nimrod Snir
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Wise R, Bishop D, Gibbs M, Govender K, James MFM, Kabambi F, Louw V, Mdladla N, Moipalai L, Motchabi-Chakane P, Nolte D, Rodseth R, Schneider F, Turton E. South African Society of Anaesthesiologists Perioperative Patient Blood Management Guidelines 2020. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Anaesthesiologists regularly request and administer blood components to their patients, a potentially life-saving intervention. All anaesthesiologists must be familiar with the indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematologists and their local haematology blood sciences laboratory is encouraged. In the last decade, there have been considerable changes in approaches to optimal use of blood components, together with the use of alternative products, with a need to update previous guidelines and adapt them for anaesthesiologists working throughout the hospital system.
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Affiliation(s)
- R Wise
- University of KwaZulu-Natal
| | | | | | | | | | | | | | - N Mdladla
- Sefako Makgatho Health Sciences University
| | | | | | - D Nolte
- University of the Witwatersrand
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Nejim B, Mathlouthi A, Weaver L, Faateh M, Arhuidese I, Malas MB. Safety of carotid artery revascularization procedures in patients with atrial fibrillation. J Vasc Surg 2020; 72:2069-2078.e4. [PMID: 32471737 DOI: 10.1016/j.jvs.2020.01.074] [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: 04/20/2019] [Accepted: 01/21/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Atrial fibrillation (Afib) is a major contributor to cerebrovascular events. Coexisting carotid artery disease is not uncommon in Afib patients, yet they have been excluded from major randomized clinical trials. Therefore, the aim of this study was to evaluate the safety of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in Afib patients. METHODS The Premier Healthcare Database was queried (2009-2015). Patients who underwent CEA or CAS were captured by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Multivariable logistic modeling was implemented to examine the outcomes: in-hospital stroke, intracerebral hemorrhage (ICH), mortality, and stroke/death. RESULTS There were 86,778 patients included. The majority were asymptomatic (n = 82,128 [94.6%]). Afib was reported in 6743 patients (7.8%). In terms of absolute outcomes in both asymptomatic and symptomatic patients, Afib patients (vs non-Afib patients) had higher mortality and stroke/death (asymptomatic: mortality, 0.4% vs 0.2%; stroke/death, 1.7% vs 1.2%; symptomatic: mortality, 6.9% vs 2.1%; stroke/death, 10.6% vs 4.5%; all P < .05). Adjusted analysis yielded higher odds of ICH (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.00-1.67), mortality (aOR, 1.59; 95% CI, 1.11-2.26), and stroke/death (aOR, 1.30; 95% CI, 1.08-1.58) in Afib patients. Although univariable analysis found Afib to be a statistically significant predictor of ischemic stroke, similar results could not be elucidated in the multivariable analysis (aOR, 1.17; 95% CI, 0.93-1.47). In Afib patients, important predictors of stroke/death included CAS (aOR, 1.80; 95% CI, 1.21-2.68) and symptomatic presentation (aOR, 5.00; 95% CI, 3.20-7.83). Other important predictors were type of preoperative medication use, age, and hospital size. CONCLUSIONS Afib was associated with worse postoperative outcomes in patients with carotid artery disease. Symptomatic status in Afib patients is associated with a stroke/death risk that is higher than in recommended guidelines for CEA and particularly for CAS. Overall, CEA was associated with lower periprocedural ICH, mortality, and stroke/death in Afib patients compared with CAS.
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Affiliation(s)
- Besma Nejim
- Division of Vascular and Endovascular Surgery, Penn State Hershey Medical Center, Hershey, Pa
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Libby Weaver
- Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md
| | - Muhammad Faateh
- Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md
| | - Isibor Arhuidese
- Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, Fla
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, Calif.
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Continuation of antithrombotic therapy increases minor bleeding but does not increase the risk other morbidities in open inguinal hernia repair: A propensity score-matched analysis. Hernia 2020; 24:857-865. [PMID: 32162110 DOI: 10.1007/s10029-020-02169-8] [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: 12/23/2019] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE An aging population has led to an increased number of patients with cardiovascular comorbidities requiring antithrombotic therapy. Perioperatively, surgeons should consider the increased risk of bleeding and thrombotic events in patients continuing or discontinuing these medications. We aimed to analyze the safety of continued antithrombotic therapy during open inguinal hernia repair. METHODS In this single-center, retrospective study, 4870 adult patients who underwent open inguinal hernia repair surgery by the same surgeon from 2008 January to 2019 March were included. Patients who underwent surgery while continuing antithrombotic therapy were included in the antithrombin group (n = 523) while those who were not under any antithrombotic therapy during the surgery were included in the control group (n = 4333). Using propensity score-matching, we then selected patients from each group with similar backgrounds. Surgery time, anesthesia time, postoperative bleeding, reoperation, and thrombotic event data were compared between the groups. Subgroup analysis based on the type of medications used was performed within the antithrombin group. RESULTS Ten patients in the antithrombin group and seven patients in the control group experienced postoperative bleeding (p < 0.001). The rate of postoperative bleeding was the highest in patients taking multiple medications. However, most were managed conservatively. Three patients from the antithrombin group experienced thrombotic events postoperatively (p = 0.001). CONCLUSIONS Patients receiving continued antithrombotic therapy had an increased risk of minor postoperative bleeding; however, they are a high-risk group for thrombotic events.
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10
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Shah A, Palmer AJR, Klein AA. Strategies to minimize intraoperative blood loss during major surgery. Br J Surg 2020; 107:e26-e38. [DOI: 10.1002/bjs.11393] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies.
Methods
This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient.
Results
Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays.
Conclusion
Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.
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Affiliation(s)
- A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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Cuevas MV, Martínez-Sancho I, Arribas J, García-Díaz C, Cuevas B. Cost of incorrect application of antithrombotic prophylaxis prior to invasive procedures. BMC Health Serv Res 2019; 19:802. [PMID: 31694621 PMCID: PMC6833205 DOI: 10.1186/s12913-019-4669-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We analyze the cost of an incorrect application, by the haematologist, of bridging anticoagulation in patients with low-risk atrial fibrillation (AF) needing interruption of treatment prior to a scheduled invasive procedure. Although not recommended, bridging therapy is widely used, resulting in avoidable costs and increased workload. METHODS Observational retrospective study. We recorded demographic and clinical data including age, sex, type of procedure, use of bridging therapy with low molecular weight heparin (LMWH), and haemorrhagic complications within 30 days of acenocoumarol withdrawal. RESULTS Acenocoumarol was stopped in 161 patients, 97 (60%) were male and 64 (40%) female. Average age was 76,11 ± 8,45 years. Procedures included: minor surgical intervention 58 (36%), colonoscopy 61 (38%), gastroscopy 11 (7%), breast biopsy 4 (2.5%), prostate biopsy 4 (2.5%), infiltration 5 (3%), and other 18 (11%). All patients received bridging anticoagulation with LMWH (40 mg enoxaparin per day) 3 days before and 3 days after the procedure (6 doses). We used a total of 966 doses, at €4.5 per unit, resulted in €4347 of total cost. No complications occurred in 156 patients (97%). Haemorrhage was observed in 5 cases: 1 major haemorrhage needing 6 days of hospital stay and transfusion, and 4 minor haemorrhages (2 patients needed emergency attendance and 2 required hospital admission for 3 and 2 days, respectively). The cost of emergency care was €237.36, and the cost of hospital stay was €6860.81 (€623.71 per day, for 11 days). The total cost of the incorrect application of the protocol was €11,445.17. CONCLUSION Guidelines about bridging anticoagulation in low risk AF patients undergoing scheduled invasive procedures were not followed. This practice increments the complications and supposes an increase in costs besides to an inadequate use of the human resources.
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Affiliation(s)
- Ma Victoria Cuevas
- Hematology Service, University Hospital of Burgos, Avenida Islas Baleares 3, 09006, Burgos, Spain.
| | | | - Jana Arribas
- Health Economics Service, University Hospital of Burgos, Avenida Islas Baleares 3, 09006, Burgos, Spain
| | - Covadonga García-Díaz
- Hematology Service, University Hospital of Burgos, Avenida Islas Baleares 3, 09006, Burgos, Spain
| | - Beatriz Cuevas
- Hematology Service, University Hospital of Burgos, Avenida Islas Baleares 3, 09006, Burgos, Spain
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12
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Rizelio V, Macuco ALB, Sato HK, Nascimento MTDMS, Souza RKMD, Kowacs PA. Stroke and transient ischemic attacks related to antiplatelet or warfarin interruption. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:456-459. [PMID: 31365636 DOI: 10.1590/0004-282x20190066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 02/14/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Patients on anticoagulant or antiplatelet therapy are often required to discontinue these medications before and during surgical or invasive procedures. In some cases, the patient stops the treatment without medical supervision. These situations may increase stroke risk. To identify the ischemic stroke and transient ischemic attack (TIA) prevalence related to length of time of discontinuation of antiplatelet or vitamin K antagonist therapy, in a group of inpatients from a specialized neurological hospital in Brazil. METHODS Cross-sectional, retrospective and descriptive study of stroke inpatients for three years. Medical reports were reviewed to find study participants, stroke characteristics, risk factors, reasons and time of drug interruption. RESULTS In three years, there were 360 stroke and TIA inpatients, of whom 27 (7.5%) had a history of antiplatelet or vitamin K antagonist interruption correlated with the time of the event (81% ischemic stroke, 19% TIA). The median time between antiplatelet interruption and an ischemic event was five days, and 62% of events occurred within seven days after drug suspension. For vitamin K antagonists, the average time to the ischemic event was 10.4 days (SD = 5.7), and in 67% of patients, the time between drug discontinuation and the event was 7-14 days. The most frequent reason for drug suspension was patient negligence (37%), followed by planned surgery or invasive examination (26%) and side effects, including hemorrhage (18.5%). CONCLUSION Antiplatelet or vitamin K antagonist suspension has a temporal relationship with the occurrence of stroke and TIA. Since these events are preventable, it is crucial that healthcare professionals convince their patients that drug withdrawal can cause serious consequences.
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Affiliation(s)
| | | | | | | | | | - Pedro André Kowacs
- Instituto de Neurologia de Curitiba; Curitiba PR, Brasil.,Universidade Federal do Paraná, Curitiba PR, Brasil
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13
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Wagner J, Lock JF, Kastner C, Klein I, Krajinovic K, Löb S, Germer CT, Wiegering A. Perioperative management of anticoagulant therapy. Innov Surg Sci 2019; 4:144-151. [PMID: 33977124 PMCID: PMC8059348 DOI: 10.1515/iss-2019-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/24/2019] [Indexed: 11/15/2022] Open
Abstract
About 10% of patients taking a chronic, oral anticoagulant therapy require an invasive procedure that can be associated with an increased risk for peri-interventional or perioperative bleeding. Depending on the risk for thromboembolism and the risk for bleeding, the physician has to decide whether the anticoagulant therapy should be interrupted or continued. Patient characteristics such as age, renal function and drug interactions must be considered. The perioperative handling of the oral anticoagulant therapy differs according to the periprocedural bleeding risk. Patients requiring a procedure with a minor risk for bleeding do not need to pause their anticoagulant therapy. For procedures with an increased risk for perioperative bleeding, the anticoagulant therapy should be adequately paused. For patients on a coumarin derivative with a high risk for a thromboembolic event, a perioperative bridging therapy with a low molecular weight heparin is recommended. Due to an increased risk for perioperative bleeding in patients on a bridging therapy, it is not recommended in patients with a low risk for thromboembolism. For patients taking a non-vitamin K oral anticoagulant, a bridging therapy is not recommended due to the fast onset and offset of the medication.
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Affiliation(s)
- Johanna Wagner
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Medical Center Julius-Maximilians, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany
| | - Johan F Lock
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany
| | - Carolin Kastner
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany
| | - Ingo Klein
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Katica Krajinovic
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Stefan Löb
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany.,Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany
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14
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Shahi A, Boe R, Bullock M, Hoedt C, Fayyad A, Miller L, Oliashirazi A. The risk factors and an evidence-based protocol for the management of persistent wound drainage after total hip and knee arthroplasty. Arthroplast Today 2019; 5:329-333. [PMID: 31516977 PMCID: PMC6728765 DOI: 10.1016/j.artd.2019.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 05/03/2019] [Accepted: 05/22/2019] [Indexed: 01/09/2023] Open
Abstract
Background Persistent wound drainage (PWD) is one of the major risk factors for periprosthetic joint infections (PJIs), arguably the most dreaded complication after total joint arthroplasty (TJA). The aim of this study was to identify the risk factors for PWD and provide a stepwise management protocol for it. Methods A retrospective review of 4873 TJAs was performed. After determining patients with PWD, a logistic regression model was designed to identify the risk factors using Charlson and Elixhauser comorbidity indexes. Finally, the protocol that was instituted for the management of PWD and its success rate was presented. Results The prevalence of PWD was 6.2% (302 of 4873). Of these, 196 did not require any surgical interventions, and drainage stopped with local wound care. 106 patients required surgical intervention, of which, 64 underwent superficial irrigation and debridement and 42 underwent deep irrigation and debridement with modular components exchange. Patients with PWD had significantly higher rates of PJI (odds ratio [OR]: 16.9; 95% confidence interval [CI]: 9.1-31.6). Risks factors were diabetes (OR: 21.2; 95% CI: 12.8-25.1), morbid obesity (OR: 17.3; 95% CI: 14.7-21.5), rheumatoid arthritis (OR: 14.2; 95% CI: 11.7-16.5), chronic alcohol use (OR: 4.3; 95% CI: 2.3-6.1), hypothyroidism (OR: 2.8; 95% CI: 1.3-4.2), and female gender (OR: 1.9; 95% CI: 1.1-2.2). Conclusions Several modifiable risk factors of PWD were identified. Surgeons must be cognizant of these comorbidities and optimize patients’ general health before an elective TJA. Our results demonstrated that PWD ceased in about 65% of the patients with local wound care measures alone. Patients with PWD were at substantially higher risk for PJI.
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Affiliation(s)
- Alisina Shahi
- Oliashirazi Institute at Marshall University, Huntington, WV, USA.,Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ, USA
| | - Richie Boe
- Oliashirazi Institute at Marshall University, Huntington, WV, USA
| | - Matthew Bullock
- Oliashirazi Institute at Marshall University, Huntington, WV, USA
| | - Chris Hoedt
- Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ, USA
| | - Azzam Fayyad
- Medcare Orthopedics and Spine Hospital, Dubai, UAE
| | - Lawrence Miller
- Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ, USA
| | - Ali Oliashirazi
- Oliashirazi Institute at Marshall University, Huntington, WV, USA
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15
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Thomaschewski M, Beyer F, Thomaschewski M, Ellebrecht D, Jonczyk M, Schneider M, Keck T, Mentler T, Hummel R. Application-based management of perioperative anticoagulant therapy: description of POPACTApp. Langenbecks Arch Surg 2019; 404:633-645. [PMID: 31209561 DOI: 10.1007/s00423-019-01796-9] [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: 01/02/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Perioperative management of oral anticoagulation (OAC) is a constant challenge in interventional and surgical procedures. When deciding to discontinue OAC, the risk of thromboembolic events must be balanced against the risk of bleeding during and after the planned procedure. These risks differ across patients and must be considered individually. METHODS POPACTApp, an application for the perioperative or peri-interventional management of oral anticoagulants, was developed using a human-centered design process (ISO 9241-210:2010). The treatment concept developed here can be adapted to a patient's individual risk profile. POPACTApp provides recommendations based on guidelines, consensus statements, and study data. After entering patient-specific risk factors, the attending physician using POPACTApp receives a clear and direct presentation of a periprocedural treatment concept, which should enable the efficient use of the program in everyday clinical practice. The perioperative treatment concept is presented via a timeline, including (1) the decision on whether to interrupt OAC, (2) the timing of the last preoperative administration of OAC in cases of interruption, (3) the decision on whether and how to bridge with heparins, and (4) the decision about when to reinitiate anticoagulation. RESULTS A task-based survey to evaluate POPACTApp's usability conducted with 20 surgeons showed that all clinicians correctly interpreted the recommendations provided by the app. Further, a questionnaire using a 7-point Likert scale from - 3 (negative) to + 3 (positive) revealed the following results to three specific questions: (1) satisfaction with the current standard procedure in the respective unit of the participant (0.15; SD = 1.57), (2) individual satisfaction with the POPACTApp application (2.7; SD = 0.47), and (3) estimation of the usefulness of POPACTApp for clinical practice (2.7; SD = 0.47). CONCLUSIONS POPACTApp provides clinicians with an individual risk-optimized treatment concept for the perioperative or peri-interventional management of OAC based on current guidelines, consensus statements, and study data, enabling the standardized perioperative handling of OAC in daily clinical practice.
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Affiliation(s)
- Michael Thomaschewski
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Florens Beyer
- Institute for Multimedia and Interactive Systems, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Martin Thomaschewski
- Center for Nano Optics, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
| | - David Ellebrecht
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Markus Jonczyk
- Department of Vascular Surgery, Academic Teaching Hospital St. Adolf-Stift, University of Hamburg, Hamburger Straße 41, 21465, Reinbek, Germany
| | - Matthias Schneider
- Department of Vascular Surgery, Academic Teaching Hospital St. Adolf-Stift, University of Hamburg, Hamburger Straße 41, 21465, Reinbek, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Tilo Mentler
- Institute for Multimedia and Interactive Systems, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Richard Hummel
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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16
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Arias Pou P, González A, Martínez LJP, Latorre AD, Alonso MS. Periprocedural management of patients receiving novel oral anticoagulants. Eur J Hosp Pharm 2019; 25:292-297. [PMID: 31157045 DOI: 10.1136/ejhpharm-2016-001088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 01/18/2017] [Accepted: 02/06/2017] [Indexed: 11/03/2022] Open
Abstract
Background Non-vitamin K oral antagonists are being increasingly used. However, broad clinical experience with them is lacking. Objectives To review guidelines and evidence for the use of non-vitamin K oral antagonists in the periprocedural environment. Results Despite the clear advantages of vitamin K oral antagonists, their use can entail risks owing to the scarcity of reversal agents. Consensus has been reached about postoperative resumption, which is recommended at 24 hours and 48-72 hours, respectively, after low-risk and high-risk bleeding surgery. Bridging with heparin is recommended in patients with a high risk of thrombosis. Urgent interventions should ideally take place 24 hours after the last dose intake. Major discrepancies exist between the American and the European recommendations for neuraxial procedures. The American proposals recommend suspending the drug for five half-lives, whereas the European approaches suggest suspension of just two half-lives. Suggestions for perioperative discontinuation vary widely. Some authors recommend a longer time of resumption for patients with renal impairment. All agree that there should be an increase in the number of days of interruption in high-risk bleeding procedures versus low-risk bleeding procedures. Conclusions A diverse number of approaches have been suggested for perioperative management of novel oral antagonists. American recommendations tend to be more rigorous than those of Europe. A need for more studies that measure health outcomes after the use of these drugs would be indispensable.
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Affiliation(s)
- Paloma Arias Pou
- Department of Hospital Pharmacy, Clínica Universidad de Navarra, Madrid, Spain
| | - Aquerreta González
- Department of Hospital Pharmacy, Clínica Universidad de Navarra, Pamplona, Spain
| | | | | | - María Serrano Alonso
- Department of Hospital Pharmacy, Clínica Universidad de Navarra, Pamplona, Spain
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17
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Makuloluwa AK, Tiew S, Briggs M. Peri-operative management of ophthalmic patients on anti-thrombotic agents: a literature review. Eye (Lond) 2019; 33:1044-1059. [PMID: 30850731 DOI: 10.1038/s41433-019-0382-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 12/25/2018] [Accepted: 01/20/2019] [Indexed: 12/14/2022] Open
Abstract
There is variability in the management of ophthalmic patients on anti-thrombotic agents (antiplatelets and anticoagulants) during the peri-operative period. A survey carried out in a UK teaching hospital on a cohort of ophthalmologists showed majority were comfortable with antiplatelet management but there was variability in managing patients on warfarin and direct oral anticoagulants (DOACs); 40% were unaware of existing guidelines. We aim to review the recommendations in the literature with regards to managing anti-thrombotic agents during the peri-operative period of ophthalmic surgery. We reviewed incidences of complications, specifically, the haemorrhagic complications associated. Pubmed search was carried out on relevant keywords from January 2007 to August 2017. All relevant UK guidelines including the Royal College of Ophthalmologists and British Society of Haematology were reviewed. Literature recommendations for routine cataract surgery under topical or sub-Tenon's anaesthesia would be to continue all anti-thrombotic agents. For sharp needle anaesthesia, avoidance of dual antiplatelet therapy was recommended and warfarin could be continued if INR within therapeutic range. Recommendations for surgeries in glaucoma, vitreo-retinal, oculoplastic and lacrimal; and strabismus are presented. No evidence was found for corneal surgery. Haemorrhagic complications are reported in all groups. Limitations of this review include the retrospective nature, lack of randomized control trials and the limited evidence regarding DOACs. It is important for ophthalmologists to be aware of and balance the risk of thromboembolic events and risks of haemorrhagic complications for ophthalmic surgery. A multi-disciplinary approach is recommended for complex cases.
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Affiliation(s)
- A K Makuloluwa
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8XP, UK.
| | - S Tiew
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8XP, UK
| | - M Briggs
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8XP, UK
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18
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Li L, Zhang W, Yang Y, Zhao L, Zhou X, Zhang J. Dental management of patient with dual antiplatelet therapy: a meta-analysis. Clin Oral Investig 2018; 23:1615-1623. [PMID: 30145662 DOI: 10.1007/s00784-018-2591-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 08/20/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND It is more common to need dual antiplatelet therapy (DAPT) for patients who had recently inserted coronary artery stent. However, the postoperative bleeding risk of patients in DAPT could significantly increase. The dental management of patients with antithrombotic therapy has always been a controversial problem. Focusing on this issue, this review discussed the available evidence to provide optimal strategy for patients taking dual antiplatelet agents in the dental setting. METHODS We searched the PubMed, Embase, ScienceDirect, Web of Science (WOS), Cochrane Library, and China National Knowledge Infrastructure (CNKI) which was performed in May 2018. Relevant articles were included according to our inclusion and exclusion criteria. Meta-analysis was conducted with fixed effects models. Subgroup analysis was used due to different dental surgeries. RESULTS Our meta-analysis included ten studies (continue DAPT vs. placebo, 535 patients vs.2907 patients). The quantitative results indicated that the risk of postoperative bleeding with continuing DAPT experienced significantly increase (RR = 1.95 95% CI [1.07, 3.54]; p = 0.03). There was no statistically significant difference between the postoperative bleeding rate and different dental surgeries (p = 0.72). CONCLUSION On the current studies, postoperative hemorrhage is exacerbated with DAPT, but it could be controlled by enhancing hemostasis methods. We recommend continuing long-term DAPT before tooth extraction. CLINICAL RELEVANCE In this work, we systematically evaluated and summarized the results of small clinical trials after reviewing the present literatures on this topic, so that we could propose more objective and more accurate evidence-based recommendations on dental management for patient with dual antiplatelet therapy.
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Affiliation(s)
- Lin Li
- Dental Student, School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Wenyi Zhang
- Department of Prosthodontics, Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Yun Yang
- Dental Student, School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Liyuan Zhao
- Dental Student, School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Xinyao Zhou
- Dental Student, School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Jian Zhang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Tianjin Medical University, Tianjin, China.
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19
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The Rate of Epistaxis Incidence in New-Generation Anticoagulants and Perioperative Approach in Otorhinolaryngological Practices. J Craniofac Surg 2018; 28:e178-e182. [PMID: 27755410 DOI: 10.1097/scs.0000000000003135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Nose bleeding is a common situation seen in otorhinolaryngological practices. One of the greatest risk factors in nose bleeding is the use of anticoagulant medicine. With the medicine developed in recent years, the risk of nose bleeding due to the frequent use of anticoagulant and antiagregant is gradually increasing.The purpose of this study is to determine the effects of especially new-generation anticoagulants on nose bleeding. In addition, the use and complications of new-generation anticoagulants and antiagregants have been compiled in light of information obtained from the literature.Three hundred forty patients whose follow-up is conducted by the cardiology department and who use oral antithrombocytic medicine have been included in the study. It has been determined that 15% of these patients use new-generation oral anticoagulants (Rivaroksaban, apiksaban, dabigatran, danaparoid) and the other patients are treated with conventional antithrombocytic treatment (Aspirin, Warfarin, Enoksaparin sodium). The rate of nose bleeding in patients who use classical anticoagulants has been observed to be 28%. In 30 of these patients who had nose bleeding, while cauterization and buffering by otorhinolaryngology specialists, major intervention has not been necessary for any of the patients. While bleeding has been observed in 26% of the patients who use new-generation anticoagulants, bleeding that required operational intervention has taken place in 2 patients. Bleedings have been stopped surgically through a large number of cauterization and buffering.While the new-generation anticoagulants cause lower rate of bleeding, it has been observed that controlling these bleedings is more difficult.
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20
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Kanthabalan A, Dawson C. Guideline for stopping anticoagulants prior to urological procedures. JOURNAL OF CLINICAL UROLOGY 2017. [DOI: 10.1177/2051415817728612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is a lack of clear evidence and guidelines on how to reverse anticoagulation prior to emergency and elective urological procedures. Our aim was to produce local hospital guidelines based on current evidence to simplify the perioperative process of stopping traditional and novel oral anticoagulants and antiplatelet therapy.
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Affiliation(s)
| | - Chris Dawson
- Department of Urology, Peterborough City Hospitals, UK
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21
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Tsukada S, Wakui M. Continuing versus discontinuing antiplatelet drugs, vasodilators, and/or cerebral ameliorators on perioperative total blood loss in total knee arthroplasty without pneumatic tourniquet. Arthroplast Today 2017; 4:89-93. [PMID: 29560402 PMCID: PMC5859674 DOI: 10.1016/j.artd.2017.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/24/2017] [Accepted: 07/04/2017] [Indexed: 12/19/2022] Open
Abstract
Background Although studies have supported the utility of perioperative continuation of antiplatelet drugs, vasodilators, and cerebral ameliorators in most procedures, no study compared total volume of blood loss after total knee arthroplasty (TKA) in patients continuing and discontinuing these drugs. Methods We retrospectively reviewed 266 consecutive patients undergoing TKA, and included 67 patients (25.2%) taking antiplatelet drugs, vasodilators, or cerebral ameliorators in this study. All TKAs were performed without a pneumatic tourniquet. The primary outcome was perioperative total blood loss calculated from blood volume and change in hemoglobin. As subgroup analysis, we compared perioperative total blood loss in patients taking antiplatelet drugs. Results There was no significant difference between the continuing group (n = 38) and discontinuing group (n = 29) in terms of the perioperative total blood loss (1025 ± 364 vs 1151 ± 327 mL, respectively; mean difference 126 mL; 95% confidence interval -45 to 298 mL; P = .15). No major bleeding or thrombotic events occurred in either group until postoperative 3-month follow-up. In patients taking antiplatelet drugs (n = 51), no significant difference was observed in the total blood loss between the continuing group (n = 30) and discontinuing group (n = 21) (1056 ± 287 vs 1151 ± 305 mL, respectively; mean difference 95 mL; 95% confidence interval -75 to 264 mL; P = .27). Conclusions No significant differences in terms of perioperative total blood loss were observed between patients continuing and discontinuing study drugs. Continuing these drugs may be preferable in the perioperative period of TKA.
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Affiliation(s)
- Sachiyuki Tsukada
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan
| | - Motohiro Wakui
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan
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22
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Hao L, Rong B, Xie F, Lin MJ, Zhong JQ. Use of dabigatran vs. warfarin with low-molecular-weight heparin bridging in catheter ablation for atrial fibrillation patients with a low CHADS2 score. Biomed Rep 2017; 6:549-554. [PMID: 28529736 DOI: 10.3892/br.2017.880] [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: 11/03/2016] [Accepted: 02/21/2017] [Indexed: 11/06/2022] Open
Abstract
The purpose of the present study was to compare the efficacy and safety of dabigatran and interrupted warfarin with low-molecular-weight heparin bridging in non-valvular atrial fibrillation (AF) catheter ablation. Previously, there has been concerns that bridging therapy increases bleeding events without the benefit of stroke prevention. It has been suggested that bridging therapy should be considered only for patients at high-risk of thrombosis. Nevertheless, bridging therapy in AF patients with a low CHADS2 score may be safe and effective. The authors performed a prospective, observational study that included consecutive 240 patients undergoing AF ablation in P.R. China. A total of 139 patients received 110 mg dabigatran twice daily and 101 patients took dose-adjusted warfarin that had been bridged with low-molecular-weight heparin. The mean patient age was 55.48 years with 72.1% being men and 74.2% having paroxysmal AF. One thromboembolic complication occurred in the dabigatran group compared to none in the warfarin group. Both the groups presented a similar major bleeding rate, total bleeding rate, and bleeding and thromboembolic complications. In patients undergoing AF ablation, the risk of bleeding or thromboembolic complications was similar for both dabigatran and interrupted warfarin with bridging therapy. Bridging therapy appeared to be safe and effective for the low-risk population.
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Affiliation(s)
- Li Hao
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, the State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Department of Cardiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Bing Rong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, the State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Department of Cardiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Fei Xie
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, the State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Department of Cardiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Ming-Jie Lin
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, the State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Department of Cardiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Jing-Quan Zhong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, the State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Department of Cardiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
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23
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Duque-Ramírez M, Díaz-Martínez JC, Marín-Velásquez JE, Velásquez-Vélez JE, Aristizábal-Aristizábal JM, Uribe-Arango W. Uso de anticoagulantes directos en situaciones especiales. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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24
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Abstract
In ophthalmology many patients undergo surgical treatment who need to take anticoagulant medication due to cardiovascular diseases. The proper handling of these drugs requires both correct assessment of the risk of thromboembolism as well as the rating of the risk of surgery-related hemorrhages. While there are established recommendations for estimation of the risk of thromboembolism based on a large body of prospective randomized trials, data regarding the evaluation of the related complications secondary to ophthalmic surgery are limited. In comparison to other surgical procedures, most interventions in ophthalmic surgery tend to have a relatively low risk of bleeding; therefore, in general there is no need to convert or discontinue anticoagulant drugs in patients undergoing opthalmic surgery. The sparse data available justifying the abrupt termination of anticoagulation are contrary to the approach currently widely distributed in clinical practice. This overview covers the relevant knowledge of the perioperative use of anticoagulant drugs. In addition, the data on the risk of hemorrhage in ophthalmological procedures are presented and discussed.
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25
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Risk stratification, perioperative and periprocedural management of the patient receiving anticoagulant therapy. J Clin Anesth 2016; 34:586-99. [PMID: 27687455 DOI: 10.1016/j.jclinane.2016.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 06/02/2016] [Accepted: 06/07/2016] [Indexed: 01/10/2023]
Abstract
As a result of the aging US population and the subsequent increase in the prevalence of coronary disease and atrial fibrillation, therapeutic use of anticoagulants has increased. Perioperative and periprocedural management of anticoagulated patients has become routine for anesthesiologists, who frequently mediate communication between the prescribing physician and the surgeon and assess the risks of both thromboembolic complications and hemorrhage. Data from randomized clinical trials on perioperative management of antithrombotic therapy are lacking. Therefore, clinical judgment is typically needed regarding decisions to continue, discontinue, bridge, or resume anticoagulation and regarding the time points when these events should occur in the perioperative period. In this review, we will discuss the most commonly used anticoagulants used in outpatient settings and discuss their management in the perioperative period. Special considerations for regional anesthesia and interventional pain procedures will also be reviewed.
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26
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Thean D, Alberghini M. Anticoagulant therapy and its impact on dental patients: a review. Aust Dent J 2016; 61:149-56. [DOI: 10.1111/adj.12344] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2015] [Indexed: 12/31/2022]
Affiliation(s)
- D Thean
- Private Practice; Gold Coast Queensland Australia
| | - M Alberghini
- Royal Perth Hospital; Perth Western Australia Australia
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27
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Iavecchia L, Safiya A, Salat D, Sabaté M, Bosch M, Biarnés A, Camps A, Castellà D, Lalueza P, Pons V, Teixidor J, Villar MM, Agustí A. Impact of Implementing a Protocol on the Perioperative Management in Patients Treated with Antithrombotics Admitted for Hip Fracture Surgery: an Observational Study. Basic Clin Pharmacol Toxicol 2016; 119:476-484. [PMID: 27151175 DOI: 10.1111/bcpt.12615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/29/2016] [Indexed: 12/11/2022]
Abstract
This study aimed to describe the impact of implementing a protocol on the perioperative management of patients admitted for hip fracture treated with antithrombotics. A protocol was designed based on the recommendations from the American College of Chest Physicians (ACCP). After its implementation (May 2012), information on antithrombotic management was collected from admission to 3 months after surgery in retrospective (October 2011-March 2012) and prospective (October 2012-March 2013) cohorts. Patients' thromboembolic risk was classified into high, moderate or low according to the ACCP categories. A total of 113 and 101 cases were included in the retrospective and prospective cohorts, respectively. No differences in age, gender, American Society of Anaesthesiology score or thrombotic risk categories were observed between cohorts. Most patients were treated with aspirin or triflusal (55.1% and 48.1% in each cohort, respectively), clopidogrel (24.5% and 26.6%) or acenocoumarol (16.3% and 20.2%). In moderate to high thromboembolic risk patients, a higher rate of bridging therapy with full doses of enoxaparin (18.5% and 50%, p = 0.04 before and 9.1% and 43.7%, p = 0.02 after surgery) and a lower rate of aspirin discontinuation (76% and 55.3%, p = 0.03) were observed in the prospective cohort. Both cohorts had a similar percentage of cases with bleeding (68.1% and 68.3%) and thrombotic events (11.5% and 13%). No differences in the timing between surgery and the discontinuation or resumption of antithrombotics were noted. After the protocol implementation, aspirin was less often stopped and bridging therapy with therapeutic doses of enoxaparin was used more often. However, interruption and resumption times of antithrombotics remained almost unchanged. In order to achieve these goals, more efforts should be made to implement the protocol in clinical practice.
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Affiliation(s)
- Luján Iavecchia
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Pharmacology, Therapeutics and Toxicology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Ahmad Safiya
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Pharmacology, Therapeutics and Toxicology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - David Salat
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain.,Clinical Pharmacology Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Mònica Sabaté
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Pharmacology, Therapeutics and Toxicology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain.,Clinical Pharmacology Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Montse Bosch
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Pharmacology, Therapeutics and Toxicology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain.,Clinical Pharmacology Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Alfons Biarnés
- Anaesthesia and Resuscitation Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Angels Camps
- Anaesthesia and Resuscitation Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Dolors Castellà
- Blood and Tissue Bank, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Pilar Lalueza
- Pharmacy Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Verònica Pons
- Haematology and Hemostasia Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jordi Teixidor
- Orthopaedics and Traumatology Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Maria M Villar
- Internal Medicine Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Antònia Agustí
- Catalan Institute of Pharmacology Foundation, Vall d'Hebron University Hospital, Barcelona, Spain. .,Department of Pharmacology, Therapeutics and Toxicology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain. .,Clinical Pharmacology Service, Vall d'Hebron University Hospital, Barcelona, Spain.
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28
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Frykholm P, Hammarskjöld F. Vascular access - guidance for success. Anaesthesia 2016; 71:494-7. [DOI: 10.1111/anae.13417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- P. Frykholm
- Department of Surgical Sciences; Anaesthesia and Intensive Care; Uppsala University; Uppsala Sweden
| | - F. Hammarskjöld
- Department of Anaesthesia and Intensive Care; Ryhov County Hospital; Jönköping Sweden
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29
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Klein AA, Arnold P, Bingham RM, Brohi K, Clark R, Collis R, Gill R, McSporran W, Moor P, Rao Baikady R, Richards T, Shinde S, Stanworth S, Walsh TS. AAGBI guidelines: the use of blood components and their alternatives 2016. Anaesthesia 2016; 71:829-42. [PMID: 27062274 DOI: 10.1111/anae.13489] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2016] [Indexed: 12/13/2022]
Abstract
Blood transfusion can be life-saving. Anaesthetists regularly request and administer blood components to their patients. All anaesthetists must be familiar with indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematology specialists and their local blood sciences laboratory is encouraged. Considerable changes in approaches to optimal use of blood components, together with the use of alternative products, have become apparent over the past decade, leading to a need to update previous guidelines and adapt them for the use of anaesthetists working throughout the hospital system.
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Affiliation(s)
- A A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - P Arnold
- Department of Paediatric Anaesthesia, Alder Hey Children's Hospital, University of Liverpool, Liverpool, UK
| | - R M Bingham
- Department of Paediatric Anaesthesia, Great Ormond Street Hospital for Children, London, UK
| | - K Brohi
- Centre for Trauma Sciences, Barts Health NHS Trust and Queen Mary University of London, London, UK
| | - R Clark
- Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK
| | - R Collis
- Department of Anaesthesia, University Hospital of Wales, Cardiff, UK
| | - R Gill
- Department of Anaesthesia, University Hospital Southampton, UK
| | | | - P Moor
- Department of Anaesthesia, Derriford Hospital, Plymouth, UK
| | - R Rao Baikady
- Department of Anaesthesia, The Royal Marsden Hospital, London, UK
| | - T Richards
- Division of Surgery and Interventional Science, University College Hospital, London, UK
| | - S Shinde
- Department of Anaesthesia, Southmead Hospital, Bristol, UK
| | - S Stanworth
- Department of Haematology, Oxford Radcliffe Hospitals, Oxford, UK
| | - T S Walsh
- Department of Anaesthetics, Critical Care and Pain Medicine, Edinburgh University, Edinburgh, UK
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30
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Abstract
Determining practice parameters for interventional procedures is challenging due to many factors including unreliable laboratory tests to measure bleeding risk, variable usage of standardized terminology for adverse events, poorly defined standards for administration of blood products, and the growing numbers of anticoagulant and antiplatelet medications. We aim to address these and other issues faced by radiologists performing invasive procedures through a review of available literature, and experiential guidance from three academic medical centers. We discuss the significant limitations with respect to using prothrombin-time and international normalized ratio to measure bleeding risk, especially in patients with synthetic defects due to liver function. Factors affecting platelet function including the impact of uremia; recent advances in laboratory testing, including platelet function testing; and thromboelastography are also discussed. A review of the existing literature of fresh-frozen plasma replacement therapy is included. The literature regarding comorbidities affecting coagulation including malignancy, liver failure, and uremia are also reviewed. Finally, the authors present a set of recommendations for laboratory thresholds, corrective transfusions, as well as withholding and restarting medications.
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31
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Green B, Mendes RA, Van der Valk R, Brennan PA. Novel anticoagulants - an update on the latest developments and management for clinicians treating patients on these drugs. J Oral Pathol Med 2016; 45:551-6. [PMID: 27028407 DOI: 10.1111/jop.12441] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 12/13/2022]
Abstract
There are several novel anticoagulant agents that are being increasingly used as an alternative to warfarin, with these drugs being reported to be at least as effective if not better. Their increased use means that oral care clinicians should have a sound understanding of the mechanism of action, pharmacology, reversal strategies and management of bleeding in patients taking these drugs. Surprisingly, there is little published in the current literature specific to professionals involved in oral health care. In this review, we provide an overview of these drugs and discuss the management of patients who need an oral procedure based on currently available literature and clinical trials.
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Affiliation(s)
- Ben Green
- Department of Gastroenterology, Torbay Hospital, Torquay, UK
| | - Rui Amaral Mendes
- Department of Oral and Maxillofacial Medicine and Diagnostic Sciences, School of Dental Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Ruben Van der Valk
- Department of Oral and Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, UK
| | - Peter A Brennan
- Department of Oral and Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, UK
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32
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Bucko A, Makris M. Pre-operative PCC for non-bleeding patients on warfarin. Thromb Res 2016; 139:158-9. [DOI: 10.1016/j.thromres.2015.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/19/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
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33
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Consolo F, Valerio L, Brizzola S, Rota P, Marazzato G, Vincoli V, Reggiani S, Redaelli A, Fiore G. On the Use of the Platelet Activity State Assay for the In Vitro Quantification of Platelet Activation in Blood Recirculating Devices for Extracorporeal Circulation. Artif Organs 2016; 40:971-980. [DOI: 10.1111/aor.12672] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Filippo Consolo
- Dipartimento di Elettronica, Informazione e Bioingegneria; Politecnico di Milano; Milano Italy
| | - Lorenzo Valerio
- Dipartimento di Elettronica, Informazione e Bioingegneria; Politecnico di Milano; Milano Italy
| | - Stefano Brizzola
- Dipartimento di Scienze Veterinarie per la Salute, la Produzione Animale e la Sicurezza Alimentare, Facoltà di Medicina Veterinaria; Università di Milano; Milano Italy
| | - Paolo Rota
- Dipartimento di Elettronica, Informazione e Bioingegneria; Politecnico di Milano; Milano Italy
| | - Giulia Marazzato
- Dipartimento di Elettronica, Informazione e Bioingegneria; Politecnico di Milano; Milano Italy
| | - Valentina Vincoli
- Dipartimento di Elettronica, Informazione e Bioingegneria; Politecnico di Milano; Milano Italy
| | | | - Alberto Redaelli
- Dipartimento di Elettronica, Informazione e Bioingegneria; Politecnico di Milano; Milano Italy
| | - Gianfranco Fiore
- Dipartimento di Elettronica, Informazione e Bioingegneria; Politecnico di Milano; Milano Italy
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34
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35
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Bailey CR, Klein AA, Hunt BJ. Blood - the most important humour?*. Anaesthesia 2014; 70 Suppl 1:1-2, e1. [DOI: 10.1111/anae.12930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- C. R. Bailey
- Department of Anaesthetics; Guy's & St Thomas' NHS Foundation Trust; London UK
| | - A. A. Klein
- Department of Anaesthetics and Intensive Care; Papworth Hospital; Cambridge UK
| | - B. J. Hunt
- Kings College University; London UK
- Consultant Haematologist, Guy's & St Thomas' NHS Foundation Trust; London UK
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