Perioperative care of the immunocompromised patient

Hemostatic challenges in patients with chronic immune thrombocytopenia treated with eltrombopag

Chronic immune thrombocytopenia (ITP) is an autoimmune disease that results in chronically low platelet counts. Treatment guidelines recommend a platelet count of at least 50 000/µl before minor surgery and at least 80 000/µl before major surgery. This retrospective analysis explored invasive non-dental procedures associated with the risk of bleeding (hemostatic challenges) among patients with chronic ITP in five phase 2/phase 3 studies of the thrombopoietin-receptor agonist, eltrombopag. Data collection for patients who underwent hemostatic challenges included demographics, study medication, timing of the procedure, platelet counts at last assessment before and first assessment after the procedure, supplemental ITP treatment, and bleeding events. Among 494 patients who participated in the studies, 87 hemostatic challenges were recorded. Median platelet counts before 44 major procedures in 32 patients were 100 000/µl and 18 500/µl among patients who received eltrombopag and placebo, respectively; before 43 minor procedures in 38 patients, median platelet counts were 82 000/µl and 20 000/µl among patients who received eltrombopag and placebo, respectively. A minority of patients required supplemental ITP treatment. Only 2 of 87 hemostatic challenges were associated with bleeding events; both patients received eltrombopag and pre-procedural platelet counts were 83 000/µl and 2000/µl. Although the number of patients who did not undergo procedures due to thrombocytopenia was not captured, these data suggest a majority of patients with chronic ITP who receive eltrombopag and experience increases in platelet counts meet current pre-procedural platelet count recommendations. The potential role of eltrombopag in supporting preparation of chronic ITP patients for surgical procedures still needs to be clinically established.

Predictors of general complications after video-assisted thoracoscopic surgical procedures

BACKGROUND

The video-assisted thoracoscopic approach has become the preferred method for many procedures due to the reduced trauma, complication rate and morbidity. The aim of this study was a risk evaluation of patients undergoing video-assisted thoracoscopic surgery (VATS) procedures.

METHODS

Between 1991 and 2004, 1,008 patients were included in this single-center retrospective analysis. Risk assessment was performed using univariate and multivariate analysis.

RESULTS

Multivariate analysis revealed that patient age (p = 0.003), the duration of the VATS procedure (p = 0.008), redo-VATS (p < 0.001) and conversion to open thoracotomy (p < 0.001) correlated significantly with the incidence of complications. Patients with immune deficiency following organ transplantation had the highest complication rate at 31.7%, which was significantly higher than for patients with either benign disease (p = 0.010) or malignant disease (p = 0.019).

CONCLUSIONS

VATS is a safe procedure, but extra caution is recommended for patients with a higher risk profile (age, redo-VATS, immune deficiency).

Oral complication risks after invasive and non-invasive dental procedures in HIV-positive patients

BACKGROUND

Limited published scientific evidence is available to provide guidance to clinicians on possible increased risks of invasive oral procedures associated with the human immunodeficiency virus (HIV) status of the patient. The aim of this study was to assess post-procedural complications in patients infected with HIV.

MATERIAL AND METHODS

This was a retrospective cross-sectional study of the records of 101 consecutive HIV patients treated at the School of Dentistry of Madrid Complutense University and Sandoval STD Clinic in Madrid between January 2003 and February 2005. Data were gathered by an experienced dental practitioner using a structured epidemiological questionnaire for information on gender, age, HIV transmission category, medical history, hepatitis B virus (HBV) or hepatitis C virus (HCV) coinfection and other diseases, TCD4+ and TCD8+ count, HIV viral load (VL), platelet count, neutrophil count, international normalized ratio and haemoglobin level; tobacco and alcohol intake, highly active antiretroviral treatment and presence of oral lesions. Information was also collected on complications related to dental treatment (invasive or non-invasive) during the previous 6 months. Chi-squared test and Fisher's exact test were used to establish statistical significance.

RESULTS

Data were gathered on 314 dental procedures in 101 patients. The overall complication rate was 2.2% (7/314); in 147 invasive procedures, seven complications (4.8%) were documented (one persistent pain, two prolonged bleeding, three infections, one bone sequestrum) including extractions, periodontal scaling, endodontic treatment and biopsy. No differences were found in TCD4+, TCD8+, platelet count, HBV or HCV co-infections or HIV VL between patients with and/or without complications. Patients with complications were mainly in B stage of HIV disease (P=0.020). Oral lesions and smoking habit>20 cig day-1 were documented in 83.3% (P=0.086) and 50% (P=0.060), respectively, of patients with complications.

CONCLUSIONS

The complication rate was 2.2% overall and 4.8% after invasive dental procedures. Presence of oral lesions, smoking habit or HIV clinical stage B may be predictive factors for oral complications in HIV patients. No relationship was found between complications and virological, immunological or other laboratory values. Studies with wider samples and negative control group are warranted to confirm the absence of an association between HIV positivity and higher risk of oral complications.

HIV status and the risk of post-extraction complications

Tooth extraction is commonly performed for patients infected with the human immunodeficiency virus (HIV). We undertook a prospective study to determine if HIV-positive patients had an increased risk for complications following tooth extraction. The study sample was composed of patients who presented for tooth extraction to the outpatient oral/maxillofacial surgery clinic at Grady Memorial Hospital, Atlanta, GA. The predictor variable was HIV status (positive or negative). The outcome variable was the presence or absence of a post-extraction complication. Other study variables were grouped into the following sets: (1) demographic, (2) past medical and social history, (3) clinical, (4) laboratory values, and (5) treatment. Between 11/93 and 4/96, 166 patients were enrolled. The study sample was composed of the 151 patients who completed the study protocol and consisted of 76 HIV-positive and 75 HIV-negative patients. The post-extraction complication rates were 22.3 and 13.3% for the HIV-positive and -negative groups, respectively (relative risk = 1.68, 95% confidence interval = 0.82 to 3.42, p = 0.15). The types of complications that occurred were similar in both groups. While the data suggest an increased rate of post-extraction complications in the HIV-positive group, the difference in complication rates between the two groups was not statistically significant. In addition, the complications were minor, self-limiting, and readily treated. Based on these findings, we believe that tooth extraction is a low-risk procedure in HIV-positive patients. Treatment may be rendered routinely to patients who present on an outpatient basis without the need for an extensive pre-operative work-up, unless otherwise indicated by relevant history.