1
|
Quality of Life and Post-Surgical Complications in Patients on Chronic Antiplatelet Therapy with Proximal Femur Fracture: 12-Month Follow-Up after Implementing a Strategy to Shorten the Time to Surgery. J Clin Med 2023; 12:jcm12031130. [PMID: 36769778 PMCID: PMC9918231 DOI: 10.3390/jcm12031130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/25/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND We evaluated a strategy to shorten the time from admission to surgery in patients with proximal femur fractures on chronic antiplatelet therapy. We reported a 12-month follow-up on complications and quality of life (QoL). METHODS Multicentre, open-label, randomized, parallel clinical trial. Patients were randomized to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Medical and surgical complications and QoL (EQ-5D-5L questionnaire) were assessed during the hospital stay, and after hospital discharge at 30 days, and 6 and 12 months. RESULTS From 156 randomized patients, 143 patients underwent surgery. The mean age was 85.5 (7.8) years and 68.0% were female. After hospital discharge, 5.7% of patients had surgical wound complications and 55.9% had medical complications, with 42.7% having serious adverse events. QoL improved significantly after surgery, with the best scores at the six-month follow-up. The overall mortality was 32.2%. There were no differences between early and delayed surgery groups in any assessed outcomes. CONCLUSION It seems safe to reduce the time of surgery under neuraxial anaesthesia in patients with hip fractures on chronic antiplatelet therapy by platelet function testing. QoL in particular improves in the first six months after surgery.
Collapse
|
2
|
Wu CT, Lien TH, Chen IL, Wang JW, Ko JY, Lee MS. The Risk of Bleeding and Adverse Events with Clopidogrel in Elective Hip and Knee Arthroplasty Patients. J Clin Med 2022; 11:jcm11071754. [PMID: 35407361 PMCID: PMC8999348 DOI: 10.3390/jcm11071754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/12/2022] [Accepted: 03/19/2022] [Indexed: 12/07/2022] Open
Abstract
Orthopedic surgeons often face a clinical dilemma on how to manage antiplatelet therapies during the time of surgery. This retrospective study is aimed to investigate the bleeding risk and adverse events in patients who hold or keep clopidogrel during elective major joints arthroplasty. Two hundred and ninety-six patients that were treated with clopidogrel while undergoing total hip or knee joint replacement between January 2009 and December 2018 were studied. Group 1 included 56 patients (18.9%) who kept using clopidogrel preoperatively. Group 2 included 240 patients who hold clopidogrel use ≥5 days preoperatively. Blood transfusion rates, estimated blood loss, complication rates, and adverse cardiocerebral events were collected and analyzed. The mean total blood loss was more in the group 1 patients as compared with that in the group 2 patients (1212.3 mL (685.8 to 2811.8) vs. 1068.9 mL (495.6 to 3294.3), p = 0.03). However, there was no significant difference between the two groups of patients regarding transfusion rates, bleeding-related complications, and infection rates. There was a trend toward a higher incidence of adverse cardiocerebral events in patients withholding clopidogrel for more than 5 days before surgery. The results of this study suggest that clopidogrel continuation could be safe and advisable for patients at thrombotic risk undergoing primary major joint replacement. Acute antiplatelet withdrawal for an extended period of time might be associated with an increased risk of postoperative thromboembolic events. More studies are required in the future to further prove this suggestion.
Collapse
Affiliation(s)
- Cheng-Ta Wu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
| | - Tzu-Hsien Lien
- Department of Family Medicine, E-Da Hospital, Kaohsiung 824, Taiwan;
| | - I-Ling Chen
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan;
| | - Jun-Wen Wang
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
| | - Jih-Yang Ko
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
| | - Mel S. Lee
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (C.-T.W.); (J.-W.W.); (J.-Y.K.)
- Correspondence: ; Tel.: +886-7-731-7123
| |
Collapse
|
3
|
Lv H, Wang J, Zhu Y, Hu Z, Wang Z, Qiao M, Jiang T. Association between osteoporosis or osteopenia and taking antiplatelet agents in general US population of NHANES. Front Endocrinol (Lausanne) 2022; 13:945159. [PMID: 36017309 PMCID: PMC9396674 DOI: 10.3389/fendo.2022.945159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/14/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Osteoporosis (OP) and osteopenia are common bone disorders in old age, and lots of patients suffering from OP or osteopenia need to take antiplatelet agents to treat basic diseases. However, clinical data on the link between osteopenia or OP and antiplatelet agents are limited. METHODS Data in this study were collected and screened from the NHANES from 2013 to 2014 and 2017 to 2018. The variables were extracted from interviews and compared between OP or osteopenia participants and normal. The relationship between OP or osteopenia and taking antiplatelet drugs was analyzed by weighted multivariate logistic regression. RESULTS After excluding individuals who were not eligible and had invalid data, we finally identified 894 participants for inclusion in the study. We found a negative association between OP or osteopenia and taking antiplatelet agents (OR = 0.53; 95% CI, 0.33-0.84; p < 0.05). These results did not change on multiple imputations (OR = 0.32, 95% CI, 0.19-0.56; p <0.01). In the subgroup analyses, the associations were more significant in women (OR = 0.18, 95% CI, 0.05-0.62; p <0.05). CONCLUSION This study demonstrated that the association between OP or osteopenia and taking antiplatelet agents was significant. Therefore, it is necessary to confirm the result by extending further research.
Collapse
Affiliation(s)
- Hao Lv
- First Affiliated Hospital, Anhui University of Chinese Medicine, Hefei, China
- Anhui University of Chinese Medicine, Hefei, China
| | - Jiuxiang Wang
- First Affiliated Hospital, Anhui University of Chinese Medicine, Hefei, China
| | - Yujun Zhu
- Anhui University of Chinese Medicine, Hefei, China
| | - Zhimu Hu
- Anhui University of Chinese Medicine, Hefei, China
| | - Ziwen Wang
- Anhui University of Chinese Medicine, Hefei, China
| | - Mingzhu Qiao
- Anhui University of Chinese Medicine, Hefei, China
| | - Ting Jiang
- First Affiliated Hospital, Anhui University of Chinese Medicine, Hefei, China
- *Correspondence: Ting Jiang,
| |
Collapse
|
4
|
Caesar U, Karlsson L, Hamrin Senorski E, Karlsson J, Hansson-Olofsson E. Delayed and cancelled orthopaedic surgery; are there solutions to reduce the complex set of problems? A systematic literature review. Int J Clin Pract 2021; 75:e14092. [PMID: 33590942 DOI: 10.1111/ijcp.14092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 02/12/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Unexpected cancellations of, and delays to, orthopaedic surgery have adverse effects, with a negative impact on hospital performance and undesirable patient outcomes. As cancellations and delays are common, finding measures to prevent them is a matter of urgency. METHODS The present systematic review conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and the Cochrane Handbook. Peer-reviewed studies reporting on cancellations or delays in patients requiring emergency orthopaedic or planned orthopaedic surgery that compared care action/intervention with no action or traditional care were included. The Grading of Recommendations Assessment, Development and Evaluation used to assess the quality of evidence of the results from the included studies. The objective of the present study was systematically to search and review the literature for qualitative evidence of factors that might reduce cancellations of and delays to orthopaedic surgical procedures. RESULTS The electronic search yielded 1209 studies and eight articles were included in the performed quality assessment. The heterogeneity of the studies and the lack of calculations and statistics in the studies resulted in no meta-analysis. The result of the quality assessment indicated that the evidence ranked from low to very low across the different outcomes. The main limiting factor, which was the reason for a decrease in quality in some outcomes, was the study designs, which were non-randomised control or retrospective approach. The interventions in the included studies could help to support a reduction in the risk of cancelled and delayed orthopaedic procedures. CONCLUSION This systematic literature review has revealed important evidence to help reduce the risk of cancelled and delayed orthopaedic procedures associated with a variety of care action exposures. They include a fast-track pathway, pre-operative guidelines and telephone contact with patients prior to surgery, as well as careful consideration of additional pre-operative tests.
Collapse
Affiliation(s)
- Ulla Caesar
- Department of Orthopaedics, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Faculty of Caring Sciences Work Life & Social Welfare, Boras University, Boras, Sweden
| | - Louise Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Jon Karlsson
- Department of Orthopaedics, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Hansson-Olofsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
5
|
Safety of early surgery for geriatric hip fracture patients taking clopidogrel: a retrospective case-control study of 120 patients in China. Chin Med J (Engl) 2021; 134:1720-1725. [PMID: 34267067 PMCID: PMC8318622 DOI: 10.1097/cm9.0000000000001668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Geriatric hip fracture patients receiving clopidogrel are a surgical challenge. In China, most of these patients undergo delayed surgical treatment after clopidogrel withdrawal for at least 5 to 7 days. However, delayed surgery is associated with increased complications and mortality in the older adults. This retrospective paralleled comparison study investigated the safety of early surgery for geriatric hip fracture patients within 5 days of clopidogrel withdrawal. Methods: Acute hip fracture patients (≥65 years) who were hospitalized in the orthogeriatric co-management ward of Beijing Jishuitan Hospital between November 2016 and April 2018 were retrospectively reviewed. Sixty patients taking clopidogrel before injury and discontinued <5 days before surgery constituted the clopidogrel group. The control group constituted 60 patients not taking antiplatelet or anticoagulant drugs and matched 1:1 with the clopidogrel group for sex, fracture type, operative procedure, and time from injury to operation (±10 h). The primary outcome was perioperative blood loss and the secondary outcomes were transfusion requirement, complications, and mortality. The Student's t test or Wilcoxon signed rank sum test was used for continuous variables and the Chi-square test was used for categorical variables. Results: Age, body mass index, American Society of Anesthesiologists score, and percentage undergoing general anesthesia were comparable between the groups (P > 0.050). The percentages of patients with coronary heart disease (61.7% vs. 18.3%; P < 0.001) and cerebrovascular disease (45.0% vs. 15.0%; P < 0.010) were significantly higher in the clopidogrel vs. control groups, respectively. The median clopidogrel discontinuation time before operation was 73.0 (range: 3.0–120.0) h. There was no significant difference in the estimated perioperative blood loss between the clopidogrel group (median: 745 mL) and control group (median: 772 mL) (P = 0.866). The intra-operative transfusion rate was higher in the clopidogrel group (22/60, 36.7%) than that in the control group (12/60, 20.0%) (P < 0.050). However, there was no significant difference in the blood transfusion rate during the entire perioperative period (26/60, 43.3% vs. 20/60, 33.3%; clopidogrel group vs. control group, respectively; P > 0.050). There was no significant difference in perioperative complications, and 30-day and 1-year mortality rates between the groups. Conclusions: Early hip fracture surgery is safe for elderly patients within 5 days of clopidogrel withdrawal, without increased perioperative blood loss, transfusion requirement, complications, and mortality compared with patients not taking antiplatelet drugs.
Collapse
|
6
|
Hip fracture and DOAC level: A retrospective study of 72 cases. Anaesth Crit Care Pain Med 2021; 40:100892. [PMID: 34058427 DOI: 10.1016/j.accpm.2021.100892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/22/2020] [Accepted: 04/02/2021] [Indexed: 11/21/2022]
|
7
|
Seasonal impact on surgical site infections in hip fracture surgery: Analysis of 330,803 cases using a nationwide inpatient database. Injury 2021; 52:898-904. [PMID: 33082026 DOI: 10.1016/j.injury.2020.10.058] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/24/2020] [Accepted: 10/13/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND As the aging population progresses, the number of elderly hip fracture patients is increasing. Elderly patients with hip fractures have a high risk of perioperative complications. One of the major complications after surgery is surgical site infection (SSI), which requires additional surgical interventions and is associated with increased mortality. Previous literature has shown that the risk of SSI is higher during the summer season in orthopedic surgery. However, little is known about the seasonal differences in the risk of SSI after hip fracture surgery. In this study, we aimed to identify the association between seasonality and SSI. METHODS We enrolled a total of 330,803 patients undergoing hip fracture surgery (65 years or older) using the Japanese Diagnosis Procedure Combination database. The study period was from April 1, 2011, to March 31, 2016. The data were analyzed to determine the association between seasonality and the incidence of SSI, debridement procedure. The primary outcome was the incidence of SSI and debridement. Other risk factors of SSI and debridement were investigated including seasons and confounders such as sex, age, BMI, smoking status, anticoagulant intake, comorbidities, surgical procedure based on medical diagnosis, waiting times for the surgery, and hospital surgical volume based on the previous literature, the risk of SSI and debridement. RESULTS Hip fracture surgeries performed in summer showed the highest risk for SSI and debridement. The risk for SSI was significantly associated with spring, and summer compared to winter (odds ratio [OR], 1.18; p, 0.016; OR, 1.19; p, 0.012, respectively). The incidence of debridement procedures after the initial surgery was also associated with spring, summer, and fall: the risk was the highest in summer (OR, 1.34; p, <0.001). Obesity, smoking history, number of comorbidities, anticoagulant intake before surgery, longer waiting time for surgery, and small hospital surgical volume were significantly associated with the risk of SSI. CONCLUSIONS We found a significant association between SSI after surgery for hip fractures and seasonality. Surgeries performed in summer had the highest risk for SSI and subsequent debridement procedures.
Collapse
|
8
|
Suciu O, Deleanu B, Haragus H, Hoinoiu T, Tudoran C, Todor A, Ghiorghitoiu A, Velimirovici N, Onofrei RR. Platelet Aggregation Inhibitors and Anticoagulants Delay Surgery for Hip Fractures. APPLIED SCIENCES 2020; 10:8617. [DOI: 10.3390/app10238617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Background: we aimed to analyze the influence of antithrombotic medication in delaying surgery for fragility hip fractures; Method: a total of 312 consecutive hip fracture cases over 55 years who underwent surgery in our Orthopedic Clinic; Results: of these, 90 patients received chronic antithrombotic medication. There were no differences between the medicated group and controls (n = 222) regarding age, gender, type of fracture and haemoglobin at admittance. However, median time to surgery was significantly longer in the medicated group: 4(3–6) days compared to 2(1–4) (p < 0.0001). By type of medication, time to surgery was: 3(1–4) days for acetylsalicylic acid (n = 44), 6(5.25–7.75) days for clopidogrel (n = 15), 4.5(4–7) days for acenocoumarin (n = 18) and 5(4–7.25) days for novel direct oral anticoagulants (n = 13). The Charlson comorbidity index was significantly higher in the medicated group: 5 [4–5] versus 4 [3–5]. There were no differences in transfusions except for fresh frozen plasma, which was administered more in the medicated patients; Conclusions: the prevalence of platelet aggregation inhibitors and anticoagulant use among fragility hip fracture patients is high, with almost a third using some form of antithrombotic medication. This may significantly lengthen time to surgery.
Collapse
|
9
|
Brink O. Hip fracture clearance: How much optimisation is necessary? Injury 2020; 51 Suppl 2:S111-S117. [PMID: 32081388 DOI: 10.1016/j.injury.2020.02.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023]
Abstract
Patients with hip fractures are typically elderly individuals with several co-morbidities. Upon admission to the hospital, they often present with acute pain, electrolyte disturbances, anaemia, coagulopathy, and delirium. Long waiting times for surgery are associated with increased morbidity and mortality. The balance between the number of clinical tests and optimisation, which may (i.e., fewer complications and better survival) or may not (i.e., more complications and increased mortality due to unnecessary surgical delay) benefit the patient, has been a preoperative challenge. This summary will review existing clinical guidelines and relevant selected studies to evaluate the extent of preoperative optimisation needed prior to hip fracture surgery.
Collapse
Affiliation(s)
- Ole Brink
- Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juel-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| |
Collapse
|
10
|
Yang Z, Ni J, Long Z, Kuang L, Gao Y, Tao S. Is hip fracture surgery safe for patients on antiplatelet drugs and is it necessary to delay surgery? A systematic review and meta-analysis. J Orthop Surg Res 2020; 15:105. [PMID: 32164755 PMCID: PMC7068917 DOI: 10.1186/s13018-020-01624-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/04/2020] [Indexed: 12/28/2022] Open
Abstract
Background Hip fractures are common and account for a large proportion of orthopedic surgical admissions in elderly patients. However, determining the timing for surgery has been controversial for patients who develop hip fractures while on antiplatelet treatment. Methods Computerized databases for studies published from the inception date to January 2020, including the Cochrane Library, PubMed (Medline), EMBASE, Web of ScienceTM, ClinicalTrials, ClinicalKey, and Google Scholar, were searched using the keywords “Hip AND Fracture”, “Antiplatelet”, “Antithrombocyte”, “Platelet aggregation inhibitors”, “Aspirin”, “Plavix”, and “Clopidogrel”. Results In total, 2328 initial articles were identified. Twenty-four studies with 5423 participants were ultimately included in our analysis. Early surgery was associated with an increased transfusion rate in the antiplatelet group compared to the non-antiplatelet group (OR = 1.21; 95% CI, 1.01 to 1.44; p = 0.03). Early surgery for hip fracture patients on antiplatelet therapy was associated with a greater decrease in hemoglobin compared to delayed surgery (WMD = 0.75; 95% CI, 0.50 to 1.00; p < 0.001). However, early surgery appeared to decrease the length of hospitalization (WMD = − 6.05; 95% CI, − 7.06 to − 5.04; p < 0.001) and mortality (OR = 0.43; 95% CI, 0.23 to 0.79; p = 0.006). Conclusion It is unnecessary to delay surgery to restore platelet function when patients with hip fractures receive antiplatelet therapy. Furthermore, early surgery can significantly reduce mortality and hospital stay, which is conducive to patient recovery. Future randomized trials should determine whether the results are sustained over time.
Collapse
Affiliation(s)
- Zhanyu Yang
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Jiangdong Ni
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China.
| | - Ze Long
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Letian Kuang
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Yongquan Gao
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| | - Shibin Tao
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, Hunan, 410000, People's Republic of China
| |
Collapse
|
11
|
A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures. J Am Acad Orthop Surg 2019; 27:887-894. [PMID: 30829898 DOI: 10.5435/jaaos-d-18-00374] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population. METHODS In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation. RESULTS After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival. DISCUSSION A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL. LEVEL OF EVIDENCE Level III, retrospective cohort study.
Collapse
|
12
|
Correoso Castellanos S, Lajara Marco F, Díez Galán M, Blay Dominguez E, Bernáldez Silvetti P, Palazón Banegas M, Lozano Requena J. Analysis of surgical delay and its influence on morbimortality in patients with hip fracture. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019. [DOI: 10.1016/j.recote.2018.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
|
13
|
Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 663] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Background Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient. Electronic supplementary material The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113, Usti nad Labem, Czech Republic.,Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003, Hradec Kralove, Czech Republic.,Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275, Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328, Bucharest, Romania
| | - Beverley J Hunt
- King's College and Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000, Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924, Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76, Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181, Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| |
Collapse
|
14
|
Imam MA, Shehata MSA, Elsehili A, Morsi M, Martin A, Shawqi M, Grubhofer F, Chirodian N, Narvani A, Ernstbrunner L. Contemporary cemented versus uncemented hemiarthroplasty for the treatment of displaced intracapsular hip fractures: a meta-analysis of forty-two thousand forty-six hips. INTERNATIONAL ORTHOPAEDICS 2019; 43:1715-1723. [PMID: 30919045 DOI: 10.1007/s00264-019-04325-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 03/15/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Controversy exists regarding the use of cement for hemiarthroplasty to treat displaced intracapsular hip fractures. The aim of this systematic review and meta-analysis was to compare the clinical outcomes between contemporary cemented and contemporary uncemented hemiarthroplasty for the treatment of displaced femoral neck fractures. METHODS Literature searches of PubMed, Scopus, Web of Science, and Cochrane Central, up to May 2017, were performed. We included randomized controlled trials (RCTs) and observational studies comparing contemporary cemented with contemporary uncemented hemiarthroplasty. Data were pooled as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) in a meta-analysis model. Studies with the Thompson and Austin Moore prostheses were excluded. RESULTS A total of 29 studies (9 RCTs and 20 observational studies), with a total of 42,046 hips, were included. Meta-analysis showed that the cemented group was associated with fewer periprosthetic fractures (RR = 0.44, 95% CI [0.21, 0.91]), longer operative time (MD = 11.25 min, 95% CI [9.85, 12.66]), more intraoperative blood loss (MD = 68.72 ml, 95% CI [50.76, 86.69]), and higher heterotopic ossification (RR = 1.79, 95% CI [1.11, 2.88]) compared with the uncemented group. Meta-analysis showed no significant difference in terms of post-operative hip function, hip pain, reoperation rate, prosthetic dislocations, aseptic loosening, wound infection, and hospital stay. CONCLUSIONS This meta-analysis shows that contemporary cemented prostheses have less intra-operative and post-operative fractures, but longer operative time, more intra-operative blood loss, and heterotopic ossifications. Otherwise, there were no significant differences between both groups.
Collapse
Affiliation(s)
- Mohamed A Imam
- Norfolk and Norwich University Hospitals, Norwich, England
| | - Mohamed S A Shehata
- Faculty of Medicine, Zagazig University, Zagazig, Egypt.,Medical Research Group of Egypt, Cairo, Egypt
| | | | - Mahmoud Morsi
- Faculty of Medicine Menoufia University, Menoufia, Egypt
| | - Alexander Martin
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK. .,, London, UK.
| | | | - Florian Grubhofer
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Nish Chirodian
- Norfolk and Norwich University Hospitals, Norwich, England
| | - Ali Narvani
- Ashford and St Peter's NHS Trust, Ashford, Kent, UK
| | | |
Collapse
|
15
|
Correoso Castellanos S, Lajara Marco F, Díez Galán MM, Blay Dominguez E, Bernáldez Silvetti PF, Palazón Banegas MA, Lozano Requena JA. Analysis of surgical delay and its influence on morbimortality in patients with hip fracture. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019; 63:246-251. [PMID: 30905545 DOI: 10.1016/j.recot.2018.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 07/18/2018] [Accepted: 07/30/2018] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Surgical delay for hip fractures (>48h) has been associated with greater adverse clinical events. However, the influence of the reasons for delay is unclear. The objective of this study was to analyse the causes of surgical delay and its influence on morbidity and mortality, in patients with hip fracture with indication for surgical treatment. MATERIAL AND METHOD A cohort of 376 hip fractures operated at our centre between January 2012 and December 2016 was retrospectively reviewed. Patients younger than 65 years and pathological fractures were excluded. Of these, 280 patients were operated with a surgical delay>48h. The causes of the delay were: antiaggregation (AG), anticoagulation (AC), medical reasons (MM), preoperative cardiac tests or administrative/organizational reasons. Surgical wound complications, general complications and mortality were compared. RESULTS There was a greater proportion of surgical wound complications in the AC group (P=.063). Patients in the AG, AC, and MM groups had higher rates of general associated complications (P=.3). Seven point fifty-one percent of the patients included died one year after surgery. The mortality rate at one year was highest in the MM group (P=.005). CONCLUSION The mortality rate was statistically significantly higher in the MM group. When comparing results, patients in the AG, AC, and MM groups presented higher rates of general complications.
Collapse
|
16
|
Mei A, Qiu L. The efficacy of tranexamic acid for orthognathic surgery: a meta-analysis of randomized controlled trials. Int J Oral Maxillofac Surg 2019; 48:1323-1328. [PMID: 30902548 DOI: 10.1016/j.ijom.2018.07.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 06/08/2018] [Accepted: 07/23/2018] [Indexed: 11/17/2022]
Abstract
The efficacy of tranexamic acid in orthognathic surgery remains controversial. We conducted a systematic review and meta-analysis to explore the influence of tranexamic acid on blood loss for orthognathic surgery. We performed a search of PubMed, Embase, Web of science, EBSCO, and Cochrane library databases through October 2017 for randomized controlled trials (RCTs) assessing the effects of tranexamic acid versus placebo on orthognathic surgery. Meta-analysis was performed using the random-effects model. Six RCTs were included in the meta-analysis. Overall, compared with placebo in orthognathic surgery, tranexamic acid administration results in significantly decreased blood loss [mean difference (MD)=-159.73; 95% confidence interval (CI)=-236.42 to -83.03; P<0.0001], and higher postoperative haemoglobin (MD=0.71; 95% CI=0.11 to 1.31; P=0.02), but has no remarkable impact on postoperative haematocrit (MD=1.23; 95% CI=-1.22 to 3.69; P=0.33) and operation time (MD=-2.35; 95% CI=-18.05 to 13.36; P=0.77). In addition, patients with orthognathic surgery need decreased amounts of irrigant fluid (MD=-229.23; 95% CI=-399.63 to -58.83; P=0.008) after using tranexamic acid. We concluded that tranexamic acid promotes the bleeding control in orthognathic surgery.
Collapse
Affiliation(s)
- A Mei
- Department of Burn and Plastic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, PR China
| | - L Qiu
- Department of Burn and Plastic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, PR China.
| |
Collapse
|
17
|
Lizaur-Utrilla A, Gonzalez-Navarro B, Vizcaya-Moreno MF, Miralles Muñoz FA, Gonzalez-Parreño S, Lopez-Prats FA. Reasons for delaying surgery following hip fractures and its impact on one year mortality. INTERNATIONAL ORTHOPAEDICS 2018; 43:441-448. [PMID: 29744645 DOI: 10.1007/s00264-018-3936-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/05/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE The purposes of this study were to identify the reasons for delayed surgery following hip fractures and analyze the impact of these reasons on 1-year mortality. METHODS A prospective cohort study of 1234 patients with mean age of 83.1 (range 65-92, SD 8.0) who underwent hip fracture surgery compared three subgroups: (1) surgery within two days from admission (609 patients); (2) delayed surgery for medical reasons (286); and (3) delayed surgery for organizational causes (339). Medical reason was defined as the need of medical optimization of the patient prior to surgery. Pre-operative assessment was performed by the American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), Hodkinson mental status, Katz index for activities of daily living, and Short-Form (SF-12) questionnaire. Univariate analyses were used (chi-square and Fisher exact or Mantel-Haenszel tests for categorical data, and variance analysis, Student t test, or Mann-Whitney U test for continuous data). Logistic regression models were used for influence of variables on complications and one year mortality. RESULTS There were no significant differences in complications or one year mortality rates between patients with surgery within two days and those with delayed surgery for medical reasons. However, the patients with delayed surgery for organizational causes had significant higher rates of both complications and one year mortality compared to the other two groups (p = 0.001). CONCLUSIONS This study suggests that waiting time for hip fracture surgery more than two days was not associated with higher complication or mortality rate if waiting was to stabilize patients with active comorbidities at admission, compared to stable patients at admission with early surgery. Although early surgery within two days from admission is desirable for stable patients at admission, in patients with complex comorbidities, the surgery should be performed once they are optimized. However, the patients with delayed surgery for organizational reasons had a significant higher rate of post-operative complications and one year mortality compared to the other two groups.
Collapse
Affiliation(s)
- Alejandro Lizaur-Utrilla
- Orthopaedic Surgery, Elda University Hospital, Miguel Hernandez University, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain. .,Traumatology and Orthopaedia, Miguel Hernandez University, Elche, Alicante, Spain.
| | - Blanca Gonzalez-Navarro
- Orthopaedic Surgery, Elda University Hospital, Miguel Hernandez University, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain
| | - Maria F Vizcaya-Moreno
- Clinical Research Group, Faculty of Health Sciences, University of Alicante, Alicante, Spain
| | - Francisco A Miralles Muñoz
- Orthopaedic Surgery, Elda University Hospital, Miguel Hernandez University, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain
| | - Santiago Gonzalez-Parreño
- Orthopaedic Surgery, Elda University Hospital, Miguel Hernandez University, Ctra Elda-Sax s/n, 03600, Elda, Alicante, Spain
| | | |
Collapse
|
18
|
Mauffrey C, Mavrogenis AF. Quality, cost and outcomes measures in orthopaedic healthcare. INTERNATIONAL ORTHOPAEDICS 2017; 41:1705-1708. [PMID: 28795215 DOI: 10.1007/s00264-017-3601-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/02/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, Denver, USA
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562, Cholargos, Athens, Greece.
| |
Collapse
|