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Butt E, Hunt W, Defty C, Hussain W, Bray A, Wernham A. A national clinician survey on the British Society for Dermatological Surgery guidelines on antithrombotic agent use in skin surgery. Clin Exp Dermatol 2024; 49:143-145. [PMID: 37697165 DOI: 10.1093/ced/llad312] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 08/04/2023] [Accepted: 09/05/2023] [Indexed: 09/13/2023]
Abstract
Antithrombotic medication is taken by 14-22% patients undergoing skin surgery, with more patients now taking direct oral anticoagulants (DOACs). The latest evidence suggests that the risk of stopping DOACs perioperatively is low in skin surgery, particularly for primary closures, but remains unclear for more complex procedures. The 2016 British Society for Dermatological Surgery (BSDS) guidelines suggest that clinicians could consider stopping DOACs in patients for 24-48 h, based on individual bleeding risk. We surveyed BSDS members to better understand clinical practice and guideline adherence with a view to updating the guidance. The results demonstrated that there is consistency among clinicians in the management of patients on more established antithrombotic agents, such as aspirin, clopidogrel and warfarin. However, there is a higher perceived risk of significant haematomas following higher-risk procedures such as larger flaps or grafts with DOACs vs. other antithrombotics postoperatively. Stopping DOACs perioperatively for 24-48 h for higher-risk procedures can be cautiously considered following an individual risk assessment and informed discussion with the patient.
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Affiliation(s)
- Eman Butt
- University Hospitals Birmingham NHS Trust, UK
| | | | | | | | - Adam Bray
- Bristol Royal Infirmary, Bristol, UK
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2
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Samaran Q, Lacombe M, Cogrel O, Chapalain M, Le Guern A, Habib F. Peri-operative management of direct Xa and IIa inhibitors for dermatologic surgery: A survey of current practice among French dermatologists. J Eur Acad Dermatol Venereol 2023; 37:e1144-e1146. [PMID: 37102461 DOI: 10.1111/jdv.19154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023]
Affiliation(s)
- Q Samaran
- Department of Dermatology, University Hospital of Montpellier and University of Montpellier, Montpellier, France
| | - M Lacombe
- Department of Dermatology, Hôpital Henri-Mondor AP-HP, Créteil, France
- Department of Dermatology, Hôpital Saint Camille, Bry-sur-Marne, France
| | - O Cogrel
- Department of Dermatology, Hôpital Saint André, University Hospital of Bordeaux and University of Bordeaux, Bordeaux, France
| | - M Chapalain
- Department of Dermatology, Hôpital Ambroise-Paré AP-HP, Boulogne-Billancourt, France
| | - A Le Guern
- Department of Dermatology, Groupement des Hôpitaux de l'Institut Catholique de Lille, Lille, France
| | - F Habib
- Skin Cancer Surgery Center, Avignon, France
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3
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Höper R, Rosen M, Kofler K, Häfner HM, Kofler L. Influence of perioperative antiplatelet and anticoagulant medication management on bleeding events in dermatosurgery-A prospective observational study. J Eur Acad Dermatol Venereol 2023; 37:1906-1913. [PMID: 37246474 DOI: 10.1111/jdv.19228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/05/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Perioperative management of antiplatelet and anticoagulant (AP/AC) therapy is a matter of balancing the risks of bleeding and thromboembolic events. Reliable data for dermatosurgery are still lacking, especially for direct oral anticoagulants (DOAC). OBJECTIVES The aim was to prospectively evaluate the influence of AP/AC-medication on bleeding risk in dermatosurgery with focus on exact intervals between DOAC intake and procedure performed on post-operative bleeding. METHODS Patients with or without AP/AC-therapy were included in the study without randomization. Exact times of DOAC-intake, procedure performed and post-operative bleeding were documented. Data collection was prospectively and standardized done by one person. RESULTS We evaluated 1852 procedures in 675 patients. Post-operative bleeding occurred after 15.93% (n = 295) of all procedures, but only a few of them were severe (1.57%, n = 29). Compared to patients without AP/AC-medication, severe post-operative bleeding occurred significantly more often under dual antiplatelet therapy (11.76%, n = 2; p = 0.0166) and bridging of either vitamin K antagonist (9.09%, n = 2; p = 0.0270) or DOAC (15.38%, n = 2; p = 0.0099). There was no significant difference in the frequency of severe bleeding regarding to the preoperative DOAC-free period. CONCLUSIONS Although AP/AC-therapy is associated with a significant higher rate of post-operative bleeding, no life-threatening bleeding was recorded. Long preoperative pausing or bridging of DOAC does not lead to significantly less severe bleeding events.
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Affiliation(s)
- Rabea Höper
- Department of Dermatology, University Medical Center, Eberhard Karls University, Tuebingen, Germany
| | - Michael Rosen
- Department of Dermatology, University Medical Center, Eberhard Karls University, Tuebingen, Germany
| | - Katrin Kofler
- Department of Dermatology, University Medical Center, Eberhard Karls University, Tuebingen, Germany
- Scientific Working Group for Anticoagulation in Dermatosurgery of the German Working Group of Dermatological Angiology (ACoDermS of the ADA)
- skin+more MVZ GmbH, Biberach, Germany
| | - Hans-Martin Häfner
- Department of Dermatology, University Medical Center, Eberhard Karls University, Tuebingen, Germany
- Scientific Working Group for Anticoagulation in Dermatosurgery of the German Working Group of Dermatological Angiology (ACoDermS of the ADA)
| | - Lukas Kofler
- Department of Dermatology, University Medical Center, Eberhard Karls University, Tuebingen, Germany
- Scientific Working Group for Anticoagulation in Dermatosurgery of the German Working Group of Dermatological Angiology (ACoDermS of the ADA)
- skin+more MVZ GmbH, Biberach, Germany
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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5
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Faraj Y, Beltrani VP. Introduction to Head and Neck Melanoma. Oral Maxillofac Surg Clin North Am 2022; 34:213-220. [DOI: 10.1016/j.coms.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Strickler AG, Shah P, Bajaj S, Mizuguchi R, Nijhawan RI, Odueyungbo M, Rossi A, Ratner D. Preventing complications in dermatologic surgery: Presurgical concerns. J Am Acad Dermatol 2021; 84:883-892. [PMID: 33497750 DOI: 10.1016/j.jaad.2020.10.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 01/19/2023]
Abstract
Cutaneous surgery has become critical to comprehensive dermatologic care, and dermatologists must therefore be equipped to manage the risks associated with surgical procedures. Complications may occur at any point along the continuum of care, and therefore assessing, managing, and preventing risk from beginning to end becomes essential. This review focuses on preventing surgical complications pre- and postoperatively as well as during the surgical procedure.
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Affiliation(s)
- Allen G Strickler
- Department of Dermatology, Geisinger Medical Center of Geisinger Commonwealth School of Medicine, Danville, Pennsylvania; Department of Laboratory Medicine, Geisinger Medical Center of Geisinger Commonwealth School of Medicine, Danville, Pennsylvania.
| | - Payal Shah
- School of Medicine, New York University Langone Health, New York, New York
| | - Shirin Bajaj
- Department of Dermatology, New York University Langone Health, New York, New York
| | - Richard Mizuguchi
- Department of Dermatology, Mount Sinai Medical School, New York, New York
| | - Rajiv I Nijhawan
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Anthony Rossi
- Weill Cornell Medical College, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Désirée Ratner
- Department of Dermatology, New York University Langone Health, New York, New York
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Lebas D, Preta LH, Leguern A, Modiano P, Wiart T. [Haemorrhagic complications following ibrutinib intake after dermatological surgery]. Ann Dermatol Venereol 2020; 147:775-779. [PMID: 32917401 DOI: 10.1016/j.annder.2020.06.023] [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: 12/16/2019] [Revised: 03/31/2020] [Accepted: 06/19/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Ibrutinib is a selective oral inhibitor of Bruton's tyrosine kinase. It is used in haematology to treat lymphoid B disorders. Haemorrhagic complications in dermatological surgery are occasionally associated with the use of anti-platelet and/or anticoagulant medication. Herein, we report a case of haemorrhage under ibrutinib following skin surgery. PATIENTS AND METHODS A 70-year-old male patient began treatment with ibrutinib for chronic lymphocytic leukaemia had 2 basal cell carcinomas of the face. The next day he had a persistent haemorrhage lasting more than 48h, with no effects on the final scarring result. DISCUSSION Ibrutinib is a tyrosine kinase inhibitor whose mechanism of action plays a role in platelet adhesion. It is known to cause haemorrhaging, either spontaneously or following invasive procedures, especially at the beginning of treatment. In the case of low-risk haemorrhagic procedures in which bleeding may be controlled by mechanical haemostasis, ibrutinib should be discontinued 3 days before and after surgery. In the event of recent initiation of ibrutinib and in the absence of urgent dermatological management, it is preferable to schedule any surgical procedures 3 months after the start of ibrutinib.
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Affiliation(s)
- D Lebas
- Service de dermatologie, université catholique de Lille, hôpital Saint-Vincent de Paul, Lille, France.
| | - L-H Preta
- Centre régional de pharmacovigilance, centre hospitalier régional universitaire de Lille, Lille, France
| | - A Leguern
- Service de dermatologie, université catholique de Lille, hôpital Saint-Vincent de Paul, Lille, France
| | - P Modiano
- Service de dermatologie, université catholique de Lille, hôpital Saint-Vincent de Paul, Lille, France
| | - T Wiart
- Service de dermatologie, université catholique de Lille, hôpital Saint-Vincent de Paul, Lille, France
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Update and Review of Bleeding Considerations in Dermatologic Surgery: Anticoagulants and Antiplatelets. Dermatol Surg 2020; 46:192-201. [PMID: 31743247 DOI: 10.1097/dss.0000000000002266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Bleeding is an unavoidable risk of dermatologic surgery. The risk may be higher in patients taking agents that affect hemostasis. OBJECTIVE The aim of this study was to provide an updated review of current anticoagulant and antiplatelet therapy available in the market and their associated risk of bleeding complications in cutaneous surgery. MATERIALS AND METHODS A review of PubMed and MEDLINE was performed to review the English-language medical literature. RESULTS Many anticoagulant and antiplatelet therapies exist. Several studies recommend the continued use of antiplatelet and anticoagulant medications in the perioperative period. Combination regimens and novel oral anticoagulants may be associated with an increased risk of bleeding. CONCLUSION An updated understanding of antiplatelet and anticoagulant agents is critical for the surgeon. Current evidence does not support the discontinuation of antiplatelet and anticoagulant agents in the perioperative period under most circumstances. However, relevant data on novel oral anticoagulant agents are still sparse, suggesting that a precautionary approach is warranted.
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Jørgensen L, Matzen RD, Albertsdottir E, Birk-Sørensen L. Complications in skin grafts when continuing antithrombotic therapy prior to cutaneous surgery requiring skin grafting: an observational study. J Plast Surg Hand Surg 2020; 54:352-357. [PMID: 32567446 DOI: 10.1080/2000656x.2020.1781141] [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] [Indexed: 10/24/2022]
Abstract
Use of anticoagulants is common and practice regarding continuation or discontinuation of the medication peri-operatively for cutaneous surgery lacks evidence-based consensus. Therefore, we aimed to do a prospective observational study with patients who were referred to cutaneous surgery and needed full thickness or split skin grafting and using antitrombotic or non-antitrombotic therapies. Data on patients characteristics, diagnosis, location of surgery and surgery performed, antithrombotic medication and complications in skin grafts were collected. Skin grafts were traced on a transparent film and areas of unhealed skin graft were marked. All patients were routinely followed-up on days 5-7 postoperative. Chi-square test, Fisher's exact test or Mann-Whitney U-test were used to compare patients taking antitrombotic medication with patients receiving no antitrombotic therapy. In addition, associations were calculated for treatment with the different antithrombotic therapies. No severe bleeding requiring blood transfusion or re-operation was observed in this study. The results showed no statistically significant difference between patients who continued treatment with antithrombotic therapy compared with patients having no antithrombotic treatment regarding sub graft hematomas or graft take. Continuing antithrombotic monotheraphy with acetylsalicylic, clopidogrel, warfarin or fish oil in relations to cutaneous surgery do not seem to increase risk of haematoma or graft lost.
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Affiliation(s)
- Lone Jørgensen
- Clinic for Surgery and Cancer Treatment and Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Reem Dina Matzen
- Department of Plastic and Reconstructive Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Elin Albertsdottir
- Department of Plastic and Breast Surgery, Zealand University Hospital, Aalborg, Denmark
| | - Lene Birk-Sørensen
- Department of Plastic and Reconstructive Surgery, Aalborg University Hospital, Aalborg, Denmark
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Taylor O, Carr C, Greif C, Garcia A, Tran S, Srivastava D, Nijhawan RI. Postoperative bleeding complications associated with blood thinning agents during Mohs micrographic surgery: A retrospective cohort study. J Am Acad Dermatol 2020; 84:225-227. [PMID: 32526317 DOI: 10.1016/j.jaad.2020.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/27/2020] [Accepted: 06/02/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Oliver Taylor
- Department of Dermatology, University of Texas Southwestern Medical School, Dallas, Texas
| | - Christian Carr
- Department of Dermatology, University of Texas Southwestern Medical School, Dallas, Texas
| | - Charlotte Greif
- Department of Dermatology, University of Texas Southwestern Medical School, Dallas, Texas
| | - Antonio Garcia
- Department of Dermatology, University of Texas Southwestern Medical School, Dallas, Texas
| | - Sophia Tran
- Department of Dermatology, University of Texas Southwestern Medical School, Dallas, Texas
| | - Divya Srivastava
- Department of Dermatology, University of Texas Southwestern Medical School, Dallas, Texas
| | - Rajiv I Nijhawan
- Department of Dermatology, University of Texas Southwestern Medical School, Dallas, Texas.
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Direct-acting Oral Anticoagulants in Dermatologic Surgery. ACTAS DERMO-SIFILIOGRAFICAS 2020. [DOI: 10.1016/j.adengl.2019.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Cabezas-Calderon V, Bassas Freixas P, García-Patos Briones V. Anticoagulantes orales directos en cirugía dermatológica. ACTAS DERMO-SIFILIOGRAFICAS 2020; 111:357-363. [DOI: 10.1016/j.ad.2019.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 12/13/2022] Open
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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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Medina A, Velasco Martinez I. Management of two major postoperative bleeding complications after mandible reconstruction with fibula free flap in a patient under chronic warfarin treatment. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2019; 6:109-115. [PMID: 32002456 PMCID: PMC6968665 DOI: 10.1080/23320885.2019.1699416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/27/2019] [Indexed: 11/06/2022]
Abstract
We present a case of two separated life-threatening postoperative bleeding complications after mandible cancer resection and microsurgical fibula flap in a patient under permanent warfarin treatment. We used fresh frozen plasma, prothrombin complex concentrate to control bleedings. We consider to maintain similar patients in heparin/enoxaparin bridging for 1–2 weeks.
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Affiliation(s)
- Abelardo Medina
- Division of Plastic Surgery, Department of Surgery, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ignacio Velasco Martinez
- Department of Oral Maxillofacial Surgery and Pathology, School of Dentistry, University of Mississippi Medical Center, Jackson, MS, USA
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15
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Abstract
Current guidelines generally recommend continuation of blood thinning drugs in dermatologic surgery and the previously used "bridging" with subcutaneous or intravenous heparin is obsolete. While the guidelines are increasingly implemented in daily practice, there is still uncertainty concerning the use of the novel direct oral anticoagulants (NOAC = DOAC). In this review, we analyze current developments and formulate concise recommendations for continuation during skin surgery under consideration of individual risk.
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16
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A Clinical Review of Common Medications Used in Emergency Dermatological Situations. Dermatol Surg 2019; 45:652-657. [PMID: 31034446 DOI: 10.1097/dss.0000000000001789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Medical emergencies can occur in any environment, including dermatologic and procedural surgical settings. There are many options available to dermatologic surgeons, which they should consider having easily accessible in the office in case an emergency arises. OBJECTIVE To summarize the current understanding about major medications that should be on-hand during dermatological surgeries. To review their mechanism of action, examine their general use, and dermatological use during surgical emergencies. METHODS AND MATERIALS A comprehensive review using PubMed was performed, searching for studies using these various medications in relation to cutaneous surgeries. RESULTS Distinct items such as hyaluronidase, nitroglycerin paste, aspirin, injectable epinephrine, and defibrillators are potential options to address various emergencies and should be readily accessible to dermatologic surgeons. CONCLUSION Dermatologic surgeons' knowledge of key medications and options to have in the office allow for a proper response in the event an emergency arises.
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Abstract
The incidence of basal cell carcinoma (BCC) is increasing as the population is aging and doubles every ten years. Surgery is the first-line treatment of BCC. Dermatological surgery is an oncological skin surgery whose first objective is to obtain a complete resection of the tumor. Its aim is also to reconstruct the defect using the optimal repair technique for the best cosmetic and scarring outcome and without functional impairment. The dermatological approach with the "oncological reading" of cutaneous tumors constitutes the essential preliminary time to the diagnosis of BCC and the identification of its limits. The perfect knowledge of the security margins in accordance with the guidelines allows a complete excision and a reconstruction in one stage under local anesthesia in the majority of cases. The surgical treatment must use 3D histology techniques or micrographic surgery to manage difficult cases of aggressive BCC in high risk zone or recurrence. Management of very aggressive BCC or locally advanced BCC is discussed in a multidisciplinary consultation by assessing the benefit/risk ratio of the surgical treatment and by identifying the appropriate surgeon after documenting the tumor, its operability and patient's adherence to the surgical treatment. © 2018. Published by Elsevier Masson SAS. All rights reserved. Cet article fait partie du numéro supplément Prise en charge des carcinomes basocellulaires difficiles à traiter réalisé avec le soutien institutionnel de Sun Pharma.
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Affiliation(s)
- J-M Amici
- Service de dermatologie, hôpital Saint-André, 1, rue Jean-Burguet, 33000 Bordeaux, France.
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18
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Hasselgren M, Runer T, Janson P, Ekström M. Antithrombotic treatment and risk of complications after head and neck full thickness skin graft surgery. J Plast Surg Hand Surg 2018; 52:333-337. [PMID: 30178690 DOI: 10.1080/2000656x.2018.1498789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Head and neck skin cancer surgery using a full thickness skin graft is a common procedure. Evidence concerning the effects of perioperative antithrombotic treatment on complications is limited. The aim of this study was to evaluate whether perioperative antithrombotic treatment is associated with risk of necrosis, bleeding or infection after full thickness skin graft surgery. Retrospective single-center cohort study with medical records review. Patients operated with a head and neck full thickness skin graft in 2010 and 2013-2015 had available data and were included. Any antithrombotic treatment was continued and all patients were routinely followed-up on days 7-10 after surgery. Data on demographics, concurrent disease, clinical characteristics, antithrombotic medications and postoperative necrosis, bleeding and infection were collected from electronic medical records. Associations with complications were examined using multivariate logistic regression adjusted for age, sex, reoperation, size of excision, site of surgery and concurrent disease. In total, 302 patients (53% women) were included. Antithrombotic treatment (n = 125 patients) was not associated with higher adjusted risk of total complications in multivariate analysis (OR 0.70; 95% CI: 0.34-1.46). In subgroup analyses, the total risk was not increased in patients on aspirin (OR 0.76; 95% CI: 0.39-1.48) or warfarin (OR 1.20; 95% CI: 0.47-3.10). In the warfarin subgroup (N = 26), there was a statistically non-significant trend towards increased risk of graft necrosis. This study supports that aspirin and warfarin should not be discontinued prior to head and neck full thickness skin graft surgery.
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Affiliation(s)
- Martin Hasselgren
- a Department of Otolaryngology Head & Neck Surgery , Blekinge Hospital , Karlskrona , Sweden
| | - Thomas Runer
- a Department of Otolaryngology Head & Neck Surgery , Blekinge Hospital , Karlskrona , Sweden
| | - Peter Janson
- a Department of Otolaryngology Head & Neck Surgery , Blekinge Hospital , Karlskrona , Sweden
| | - Magnus Ekström
- b Division of Respiratory Medicine and Allergology, Department of Clinical Sciences , Lund University , Lund , Sweden
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20
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Amici JM. [Haemorrhagic risk associated with skin cancer surgery: AMIF! (accept, manage, inform, follow-up)]. Ann Dermatol Venereol 2017; 145:229-230. [PMID: 29180237 DOI: 10.1016/j.annder.2017.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- J-M Amici
- Service de dermatologie, hôpital Saint-André, 1, rue Jean-Burguet, 33000 Bordeaux, France.
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21
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Say M, Dupin N, Stieltjes N, Avril MF, Aractingi S, Chanal J. [Dermatologic surgery, hemophilia and Von Willebrand disease]. Ann Dermatol Venereol 2017; 145:233-239. [PMID: 29150153 DOI: 10.1016/j.annder.2017.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/02/2017] [Accepted: 10/03/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Von Willebrand disease (VWD) and hemophilia A and B are the most common types of hereditary coagulation-factor deficiencies. The frequency and type of complications of skin surgery in these patients are unknown. The increasing incidence of skin cancer prompted us to reflect upon this issue. While the incidence of skin cancer is increasing, the complications of skin surgery or ablative laser treatment remain unknown in this population. AIM The aim of this study was to determine the frequency of bleeding complications during and after skin surgery in patients with a hereditary coagulation-factor deficiency (hemophilia or VWD). PATIENTS AND METHODS We conducted a retrospective study in patients with hemophilia A or B or VWD undergoing skin surgery or ablative laser treatment at the Dermatology Department of the Cochin Hospital in Paris, France. RESULTS Fourteen procedures were performed in 8 patients. Three episodes of bleeding occurred (n=3/14, 21.4%): one hematoma, one delayed bleed and one immediate bleed. None of these complications required surgical revision or resuscitation. DISCUSSION The rate of hemorrhagic complications was higher than in the general population. However, these complications can be considered non-serious and the risk-benefit ratio remains favorable. Multidisciplinary management and coordination with the reference hemophilia center are mandatory in this population to establish a coagulation-factor (CF) substitution protocol suited to the disease characteristics and the surgical procedure.
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Affiliation(s)
- M Say
- Service de dermatologie, centre Tarnier, hôpital Cochin, AP-HP, 89, avenue d'Assas, 75006 Paris, France
| | - N Dupin
- Service de dermatologie, centre Tarnier, hôpital Cochin, AP-HP, 89, avenue d'Assas, 75006 Paris, France; Université Paris 5, 15, rue de l'École-de-Médecine, 75006 Paris, France
| | - N Stieltjes
- Centre d'accueil et de traitement des hémophiles, hôpital Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - M-F Avril
- Service de dermatologie, centre Tarnier, hôpital Cochin, AP-HP, 89, avenue d'Assas, 75006 Paris, France; Université Paris 5, 15, rue de l'École-de-Médecine, 75006 Paris, France
| | - S Aractingi
- Service de dermatologie, centre Tarnier, hôpital Cochin, AP-HP, 89, avenue d'Assas, 75006 Paris, France; Université Paris 5, 15, rue de l'École-de-Médecine, 75006 Paris, France
| | - J Chanal
- Service de dermatologie, centre Tarnier, hôpital Cochin, AP-HP, 89, avenue d'Assas, 75006 Paris, France; Université Paris 5, 15, rue de l'École-de-Médecine, 75006 Paris, France.
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22
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Struk S, Correia N, Guenane Y, Revol M, Cristofari S. Full-thickness skin grafts for lower leg defects coverage: Interest of postoperative immobilization. ANN CHIR PLAST ESTH 2017; 63:229-233. [PMID: 28986118 DOI: 10.1016/j.anplas.2017.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 08/22/2017] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Full-thickness skin graft is an effective reconstruction method after excision of skin lesions on the lower limb that are not amenable to primary closure. The randomness of graft take is the major drawback of this procedure. OBJECTIVE The objective of the study was to evaluate the outcome of full-thickness skin grafts (FTSG), used to repair lower leg defects after excision of skin lesions, after a 5-day immobilization period. MATERIAL AND METHODS All consecutive patients who underwent FTSG to cover defects below the knee between November 2011 and January 2016 were retrospective reviewed. Graft take was assessed and defined as good (>90% graft take), moderate (between 50% and 90% graft take), or poor (<50% graft take). RESULTS Seventy patients were included. Median age was 70 years (range, 18-92 years). The median area of the defect was 12cm2. Graft take was good in 64 patients (91.4%), moderate in 3 patients (4.3%), and poor in 3 patients (4.3%) at Day 5. Complications included hematoma (11%), infection (14%) and venous thrombosis (3%). CONCLUSION Full-thickness skin graft is a reliable method to repair defects on the lower leg after removal of skin lesions. A 5-day immobilization period can improve the graft take. The authors have indicated no significant interest with commercial supporters.
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Affiliation(s)
- S Struk
- Université Paris-Diderot, Sorbonne Paris Cité, Paris, France; Hôpital Saint-Louis, AP-HP, 75010 Paris, France.
| | - N Correia
- Chirurgie plastique reconstructrice et esthétique, hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51100 Reims, France
| | - Y Guenane
- Université Paris-Diderot, Sorbonne Paris Cité, Paris, France; Hôpital Saint-Louis, AP-HP, 75010 Paris, France
| | - M Revol
- Université Paris-Diderot, Sorbonne Paris Cité, Paris, France; Hôpital Saint-Louis, AP-HP, 75010 Paris, France
| | - S Cristofari
- Université Paris-Diderot, Sorbonne Paris Cité, Paris, France; Hôpital Saint-Louis, AP-HP, 75010 Paris, France
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Hunt WT, O'Sullivan NA, Donnelly A. Evaluation of Australian dermatological postoperative patient information leaflets: Should we have a national checklist? Australas J Dermatol 2017; 59:118-123. [PMID: 28425573 DOI: 10.1111/ajd.12614] [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: 09/09/2016] [Accepted: 12/19/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Patient information leaflets (PILs) are frequently provided to patients following dermatological surgery to provide advice and reassurance in the community. This evaluation reviewed the guidance specified in postoperative PILs across the 40 Australian dermatology teaching departments and clinics. METHODS All 40 departments and clinics were identified and asked to provide their postoperative information leaflets on sutured wound care (preferable) or excision biopsy (September-October 2015). For each PIL, 10 preselected parameters were evaluated. RESULTS In total, 28/40 (70%) of units responded. From these units, 11/28 (39.3%) stated they do not use a postoperative PIL. Of the 17 units that provided PILs, the mode minimum dressing duration was 24 (6/17; 35.3%) and 48 h (6/17; 35.3%). For haemostatic advice, 12 PILs specified the time to press on a bleeding wound, with the most common advice being 10 (3/12; 25%) and 20 min (3/12; 25%). Of the 14 PILs that provided analgesic advice, the mode information suggested using paracetamol only and avoiding aspirin (4/14, 28.6%). Two or more signs of infection were stated in 11/17 (64.7%) PILs; 7/17 (41.2%) advised applying petroleum jelly to the wound, almost all PILs highlighted the contact for postoperative problems 16/17 (94.1%), and 5/17 (29.4%) leaflets mentioned scarring. Altogether 8/17 (47.1%) of PILs advised on the timeframe until active exercise could resume postoperatively. CONCLUSION Guidance provided in Australian postoperative dermatological PILs is heterogeneous. A consensus checklist or template would be beneficial and ensure that advice provided to patients is more consistent; this could be adapted for local factors.
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Affiliation(s)
- William Tn Hunt
- Dermatology Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | | | - Alan Donnelly
- Dermatology Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
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24
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Koenen W, Kunte C, Hartmann D, Breuninger H, Moehrle M, Bechara F, Schulze H, Lösler A, Löser C, Wetzig T, Pappai D, Rapprich S, Weiß C, Faulhaber J. Prospective multicentre cohort study on 9154 surgical procedures to assess the risk of postoperative bleeding - a DESSI study. J Eur Acad Dermatol Venereol 2017; 31:724-731. [DOI: 10.1111/jdv.14080] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 11/22/2016] [Indexed: 12/21/2022]
Affiliation(s)
- W. Koenen
- Department of Dermatology and Allergy; University Hospital Mannheim; Mannheim Germany
| | - C. Kunte
- Department of Dermatology and Allergy; University Hospital Munich (LMU); Munich Germany
| | - D. Hartmann
- Department of Dermatology and Allergy; University Hospital Munich (LMU); Munich Germany
| | - H. Breuninger
- Department of Dermatology; University Hospital Tübingen; Tübingen Germany
| | - M. Moehrle
- Department of Dermatology; University Hospital Tübingen; Tübingen Germany
| | - F.G. Bechara
- Department of Dermatology, Venereology and Allergology; Ruhr-University Bochum; Bochum Germany
| | - H.J. Schulze
- Department of Dermatology; Center for Skin Tumors; Münster-Hornheide; Münster Germany
| | - A. Lösler
- Department of Dermatology; Center for Skin Tumors; Münster-Hornheide; Münster Germany
| | - C.R. Löser
- Dermatology Hospital and Skin Tumor Center; Ludwigshafen Hospital; Ludwigshafen Germany
| | - T. Wetzig
- Department of Dermatology, Venereology and Allergology; University of Leipzig Medical Centre; Leipzig Germany
| | - D. Pappai
- Department of Dermatology; University Hospital Münster; Münster Germany
| | - S. Rapprich
- Department of Dermatology; Hospital of Darmstadt; Darmstadt Germany
| | - C. Weiß
- Department of Biostatistics; University Hospital Mannheim; Mannheim Germany
| | - J. Faulhaber
- Department of Dermatology and Allergy; University Hospital Mannheim; Mannheim Germany
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Abstract
Scarring is the response elicited by the skin surface to injury and loss of tissue material. Wound healing takes place through a complex natural repair system consisting of vascular, inflammatory and proliferative phenomena, followed by a remodelling and cell apoptosis phase. This incredible repair system is inevitable, but sometimes unpredictable due to individual differences based on multiple factors. The scar is the objective criterion of a skin surgery, both for the patient and the dermsurgeon. It is therefore crucial to establish with the patient during the preoperative consultation, the size and positioning of the expected scar, taking into account the oncologic, anatomic and surgical constraints. Scars can ideally blend into normal skin, but may also give rise to various abnormalities. We can manage and prevent these abnormalities by mastering initial inflammation, that may induce hyperpigmentation and hypertrophy. Early massage using cortocosteroid topic or anti-inflammatory moisturizers may be effective. Random individual scarring may be minimized by a dynamic personalized accompanying scarring.
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Affiliation(s)
- J M Amici
- Service de dermatologie, hôpital Saint-André, Bordeaux, France.
| | - V Chaussade
- Service de dermatologie, hôpital Saint-André, Bordeaux, France
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Halaszynski TM. Administration of Coagulation-Altering Therapy in the Patient Presenting for Oral Health and Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am 2016; 28:443-460. [PMID: 27745616 DOI: 10.1016/j.coms.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Oral health care providers are concerned with how to manage patients prescribed coagulation-altering therapy during the perioperative/periprocedural period for dental and oral surgery interventions. Management and recommendation can be based on medication pharmacology and the clinical relevance of coagulation factor levels/deficiencies. Caution should be used with concurrent use of medications that affect other components of the clotting mechanisms; prompt diagnosis and any necessary intervention to optimize outcome is warranted. However, evidence-based data on management of anticoagulation therapy during oral and maxillofacial surgery/interventions is lacking. Therefore, clinical understanding and judgment are needed along with appropriate guidelines matching patient- and intervention-specific recommendations.
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Affiliation(s)
- Thomas M Halaszynski
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3 Library, New Haven, CT 203 785-2804, USA.
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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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28
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George SMC, Sherley-Dale AC. Skin surgery, an evidence-based update: meeting report. Br J Dermatol 2016; 174:763-9. [PMID: 26987559 DOI: 10.1111/bjd.14438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2015] [Indexed: 11/30/2022]
Abstract
The Evidence Based Update on Skin Surgery was held in Nottingham in May 2015. The meeting featured presentations on new diagnostic techniques, trials in development, discussions of recently published trials, and a question and answer session with an expert panel. This report aims to summarize the presentations and discussions from the day.
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Affiliation(s)
- S M C George
- Department of Dermatology, Eastbourne District General Hospital, Kings Drive, Eastbourne, East Sussex, BN21 2UD, U.K
| | - A C Sherley-Dale
- Department of Dermatology, Royal South Hants Hospital, Southampton University Hospitals NHS Trust, Southampton, U.K
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29
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Acute pain management in dermatology. J Am Acad Dermatol 2015; 73:543-60; quiz 561-2. [DOI: 10.1016/j.jaad.2015.04.050] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 04/08/2015] [Accepted: 04/08/2015] [Indexed: 02/02/2023]
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30
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Amici JM. Don't stop antithrombotics for cutaneous surgery: just do it now! Br J Dermatol 2015; 172:555-6. [DOI: 10.1111/bjd.13603] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- J.-M. Amici
- Service de Dermatologie; Hôpital Saint André 1; Rue Jean Burguet; 33075 Bordeaux CEDEX France
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