The effect of preoperative antiplatelet therapy in coronary artery surgery: blood transfusion requirements for patients on cardiopulmonary bypass

Risk factors for platelet transfusion in glioblastoma surgery

The objectives of this study are to identify risk factors for and to evaluate clinical outcomes of platelet transfusion in glioblastoma surgery. The medical records of adult patients who underwent craniotomy for glioblastoma resection at a single academic medical center were retrospectively reviewed. We stratified patients into 2 groups: those who were transfused at least 1 unit of platelets intraoperatively or postoperatively (no more than 7 days after surgery), and those who were not transfused with platelets. Through the use of a 1:3 matched cohort analysis, we compared complications, length of stay, discharge disposition, and mortality, across groups. One hundred and five consecutive adult patients were included in this study. Thirteen patients (12.38%) received platelet transfusions. Prior antiplatelet therapy (odds ratio [OR] 8.21, 95% confidence interval [CI]: 2.36-28.58), preoperative platelet count less than 200,000 cells/µL (OR 8.46, 95% CI: 2.16-33.22), and longer operative times (OR 1.73, 95% CI: 1.10-2.72) were significant risk factors for platelet transfusion. There were no significant differences in the outcomes of interest in the matched cohort analysis.

Decision making after aspirin, clopidogrel and GPIIb/IIIa inhibitor use

The expanding use of antiplatelet agents in patients who undergo coronary bypass grafting raises the problem of balancing the benefit of this treatment and the risk of increased bleeding after surgery. Aspirin and clopidogrel have different mechanisms of actions, but have in common the irreversibility of the inhibition mechanism. Even if platelets half-life is around 10 days, it is not necessary to wait for this period of time. It can be reasonable to discontinue aspirin two to three days and clopidogrel five days before surgery, even if it was recently suggested to reduce the discontinuation interval to two to three days for the clopidogrel as well. GPIIb/IIIa inhibitors have a short acting action. Reasonably, abciximab has to be stopped, when possible, at least 12 hours before surgery, preferably before 24 hours. On the contrary, tirofiban can also be stopped at the moment of skin incision without harmful effects. Very little is known of eptifibatide, but it seems that it is safe to stop it two to four hours before surgery. Patients with acute coronary syndrome do not need to discontinue any antiplatelet treatment.

Clopidogrel in the management of acute coronary syndromes: indications, results, obstacles

Atherothrombosis is the underlying pathology of the acute coronary syndromes (ACS), in which platelet activation plays a key role. Therefore, antiplatelet therapy is an essential component of guideline-recommended ACS management. Considerable evidence clearly demonstrates the benefits of the antiplatelet agent clopidogrel in reducing mortality, decreasing recurrent cardiovascular events, and increasing arterial patency in ACS patients. Despite this evidence, data from patient registries and clinical initiatives such as CRUSADE (Can Rapid stratification of Unstable angina Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines) and GRACE (Global Registry of Acute Coronary Events) indicate that clopidogrel is underused in patients with ACS. This is especially true for patients receiving conservative medical management, many of whom have significant risk for recurrent ischemic events. The purpose of this review is to compare "real-life" clopidogrel therapy with evidence-based guidelines, and to highlight clinical factors that drive clopidogrel implementation or provide barriers to its use in ACS patients.

Blood conservation strategies in cardiac surgery

Despite the continuous efforts to increase the safety of blood components, red blood cell transfusions remain associated with some risks and side effects. Therefore, numerous techniques have been developed to decrease blood use, but they also carry risks and bear costs. Most of them are frequently used in cardiac surgery, which still consumes a large part of the available blood supply. Among western countries the use of alternative techniques, but also transfusion practice, has been shown to vary markedly. 'Blood conservation' is a global concept engulfing all possible strategies aimed at reducing patients' exposure to allogeneic blood components. The development of the 'best strategy' consists of the selection of those techniques that are most appropriate to the local specific situation. It implies the establishment of a reliable system, collecting data both at the surgical team and at the medical level.