1
|
Pozzi A, Lucà F, Gelsomino S, Abrignani MG, Giubilato S, Di Fusco SA, Rao CM, Cornara S, Caretta G, Ceravolo R, Parrini I, Geraci G, Riccio C, Grimaldi M, Colivicchi F, Oliva F, Gulizia MM. Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures. J Clin Med 2024; 13:2451. [PMID: 38730979 PMCID: PMC11084691 DOI: 10.3390/jcm13092451] [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: 12/31/2023] [Revised: 02/22/2024] [Accepted: 04/07/2024] [Indexed: 05/13/2024] Open
Abstract
In clinical practice, the number of patients treated with direct oral anticoagulants (DOACs) has consistently increased over the years. Since anticoagulant therapy has been associated with an annual incidence of major bleeding (MB) events of approximately 2% to 3.5%, it is of paramount importance to understand how to manage anticoagulated patients with major or life-threatening bleeding. A considerable number of these patients' conditions necessitate hospitalization, and the administration of reversal agents may be imperative to manage and control bleeding episodes effectively. Importantly, effective strategies for reversing the anticoagulant effects of DOACs have been well recognized. Specifically, idarucizumab has obtained regulatory approval for the reversal of dabigatran, and andexanet alfa has recently been approved for reversing the effects of apixaban or rivaroxaban in patients experiencing life-threatening or uncontrolled bleeding events. Moreover, continuous endeavors are being made to develop supplementary reversal agents. In emergency scenarios where specific reversal agents might not be accessible, non-specific hemostatic agents such as prothrombin complex concentrate can be utilized to neutralize the anticoagulant effects of DOACs. However, it is paramount to emphasize that specific reversal agents, characterized by their efficacy and safety, should be the preferred choice when suitable. Moreover, it is worth noting that adherence to the guidelines for the reversal agents is poor, and there is a notable gap between international recommendations and actual clinical practices in this regard. This narrative review aims to provide physicians with a practical approach to managing specific reversal agents.
Collapse
Affiliation(s)
- Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6229 HX Maastricht, The Netherlands
| | | | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy;
| | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | - Giorgio Caretta
- Sant’Andrea Hospital, ASL 5 Regione Liguria, 19124 La Spezia, Italy;
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy;
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy;
| | - Giovanna Geraci
- Cardiology Unit, S. Antonio Abate Hospital, ASP Trapani, 91016 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy;
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy;
| | | |
Collapse
|
2
|
Andronic D, Andronic O, Ammann E, Pravin E, Cubberley R. Outcomes of different perioperative management strategies of patients on chronic anticoagulation in elective total hip and knee arthroplasty: a systematic review. Fam Pract 2024:cmae020. [PMID: 38641558 DOI: 10.1093/fampra/cmae020] [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: 04/21/2024] Open
Abstract
INTRODUCTION There are currently different management guidelines for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) that are on long-term anticoagulation. The timing of discontinuation and restarting the anticoagulation is challenging during the postoperative care, which often involves general practitioners and physiotherapists. METHODS The systematic review followed the PRISMA guidelines and included 3 databases: PubMed/MEDLINE, EMBASE, and Web of Science Core Collection. It was registered in the International Prospective Register for Systematic Reviews and Meta-analysis (PROSPERO) under the registration number: CRD42023408906. The risk of bias assessment was performed using the Methodological index for non-randomized studies (MINORS) criteria. RESULTS Six retrospective studies involving 727 patients with therapeutic anticoagulation (1,540 controls) for elective THA, TKA and revision arthroplasty have been included. The follow-up ranged from 30 days to 1 year postoperatively. All studies evaluated outcomes of warfarin therapeutic anticoagulation versus prophylactic dosages of one or more of the following: warfarin, aspirin, low-molecular-weight heparin (LMWH) and unfractionated low-dose heparin (UFH). One study did not discontinue therapeutic anticoagulation. Two studies reported no significant differences in complications between groups, whilst 3 studies had significantly higher rates of superficial wound infections, revision surgeries, postoperative haematomas, and prosthetic joint infections (PJI). CONCLUSION Different anticoagulation-related perioperative management strategies achieve different outcomes following elective arthroplasty in patients with therapeutic chronic anticoagulation. There is contradictory evidence regarding the need for the discontinuation of therapeutic warfarin. Retrospective data showed that individual risk stratification with multi-modal prophylaxis resulted in minimal complications. LEVEL OF EVIDENCE Systematic Review of Level III studies.
Collapse
Affiliation(s)
- Diana Andronic
- School of Allied Health, Faculty of Health, Education, Medicine & Social Care ARU, Cambridge, United Kingdom
| | - Octavian Andronic
- Department of Trauma and Orthopaedics, Balgrist University Hospital, Zürich, Switzerland
| | - Elias Ammann
- Department of Trauma and Orthopaedics, Perth Orthopaedics and Sports Medicine Centre, Perth, Australia
| | - Edward Pravin
- Faculty of Medicine, Curtin University, Perth, Australia
| | - Rachael Cubberley
- School of Allied Health, Faculty of Health, Education, Medicine & Social Care ARU, Cambridge, United Kingdom
| |
Collapse
|
3
|
Brannigan JFM, Gillespie CS, Adegboyega G, Watson M, Lee KS, Mazzoleni A, Goacher E, Mantle O, Omar V, Gamage G, Yanez Touzet A, Mowforth O, Thomas W, Uprichard J, Hutchinson PJ, Stubbs DJ, Davies BM. Impact of antithrombotic agents on outcomes in patients requiring surgery for chronic subdural haematoma: a systematic review and meta-analysis. Br J Neurosurg 2024:1-8. [PMID: 38584489 DOI: 10.1080/02688697.2024.2333399] [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: 12/14/2023] [Accepted: 03/12/2024] [Indexed: 04/09/2024]
Abstract
A chronic subdural haematoma (CSDH) is a collection of aged blood between the dura and the brain, typically treated with surgical evacuation. Many patients with CSDH have comorbidities requiring the use of antithrombotic medications. The optimal management of these medications in the context of CSDH remains unknown, as the risk of recurrence must be carefully weighed against the risk of vaso-occlusive events. To better understand these risks and inform the development of clinical practice guidelines, we conducted a systematic review and meta-analysis. A systematic review was conducted in accordance with the PRISMA guidelines, searching Medline and Embase databases. The study was registered with PROSPERO (CRD42023397061). A total of 44 studies were included, encompassing 1 prospective cohort study and 43 retrospective cohort studies. Pooled odds ratios (ORs) were calculated for CSDH recurrence and vaso-occlusive events in patients taking anticoagulant or antiplatelet medications compared to patients not receiving antithrombotic therapy. GRADE was used to assess the quality of evidence. In patients on anticoagulant therapy at CSDH diagnosis, the pooled OR for CSDH recurrence was 1.41 (95% CI 1.11 to 1.79; I2 = 28%). For patients on antiplatelet therapy, the pooled OR was 1.31 (95% CI 1.08 to 1.58; I2 = 32%). Patients taking antithrombotic medications had a significantly higher risk of vaso-occlusive events, with a pooled OR of 3.74 (95% CI 2.12 to 6.60; I2 = 0%). There was insufficient evidence to assess the impact of time to recommence antithrombotic medication on CSDH outcomes. We found that baseline antithrombotic use is associated with the risk of CSDH recurrence and vaso-occlusive events following surgical evacuation. The evidence base is of low quality, and decisions regarding antithrombotic therapy should be individualised for each patient. Further high-quality, prospective studies or registry-based designs are needed to better inform clinical decision-making and establish evidence-based guidelines.
Collapse
Affiliation(s)
- Jamie F M Brannigan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Conor S Gillespie
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Gideon Adegboyega
- Addenbrookes Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Matthew Watson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Adele Mazzoleni
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Edward Goacher
- Sheffield University Teaching Hospitals NHS Trust, Sheffield, UK
| | | | - Vian Omar
- University of Buckingham Medical School, Buckingham, UK
| | - Githmi Gamage
- Royal College of Surgeons of Ireland, Dublin, Republic of Ireland
| | - Alvaro Yanez Touzet
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Oliver Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation trust, Cambridge, UK
| | - James Uprichard
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Daniel J Stubbs
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, London, UK
- Division of Anaesthesia, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| |
Collapse
|
4
|
Boyi T, Richmond RL, Kayastha D, Manes RP, Rimmer R. Restarting Antithrombotic Therapies After Endoscopic Sinus Surgery: A Systematic Review. Ann Otol Rhinol Laryngol 2024:34894241245840. [PMID: 38557289 DOI: 10.1177/00034894241245840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Antithrombotic therapies, comprised of both anticoagulant and antiplatelet agents, are routinely paused prior to endoscopic sinus surgery (ESS) to reduce the risk of perioperative hemorrhage. At present, no clear guidelines exist to guide otolaryngologists on when to resume these agents after ESS. Our goal was to systematically review the existing literature related to this topic. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically queried the PubMed, Embase, Ovid, Web of Science, Cochrane, and CINAHL databases to identify publications reporting on antithrombotic and antiplatelet therapy in the context of ESS. The primary outcomes we sought were recommendations on the timing of antithrombotic therapy resumption after ESS. RESULTS Of the 104 unique articles identified, all were screened for relevance by 2 independent reviewers based on title and abstract, 20 underwent full-text review, and 6 met inclusion criteria for analysis. Of these, 3 were literature reviews, 2 were case-control studies, and 1 was a cohort study. All publications discussed when to pause antithrombotic therapy prior to surgery while only 3 articles discussed resumption of these agents. Recommendations were mixed. CONCLUSION A paucity of literature exists on the resumption of antithrombotic therapies after ESS. As a major determining factor in patient morbidity, guideline-based resumption of these therapies is needed.
Collapse
Affiliation(s)
- Trinithas Boyi
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Rhys L Richmond
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Darpan Kayastha
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - R Peter Manes
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Ryan Rimmer
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
5
|
Allyn S, Bentov N, Dillon J. Perioperative Optimization and Management of the Oral and Maxillofacial Surgical Patient: A Narrative Review on Updates in Anticoagulation, Hypertension and Diabetes Medications. J Oral Maxillofac Surg 2024; 82:364-375. [PMID: 38103577 DOI: 10.1016/j.joms.2023.11.015] [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: 05/08/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE The preoperative management guidelines of surgical patients are constantly evolving as newer evidence-based research is published. Oral and maxillofacial surgeons need to be current with the increasingly more complex new drug therapies and updated national association(s) guidelines. This narrative review provides a synopsis with important reference tables for updated preoperative optimization guidelines for anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control in the preoperative period for the oral and maxillofacial surgery patient. It also includes the most current anesthesia guidelines on glucagon-like peptide receptor agonists. METHODS The search strategy utilized pubmed.gov to identify the most recent national society guidelines and review articles pertinent to perioperative anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control. RESULTS The search identified 75 articles from the American College of Surgeons, American Heart Association, American Society of Anesthesiologists, American College of Cardiologists, in addition to recent reviews discussing the standard of care for optimization of patients in the perioperative period. CONCLUSION Medical optimization prior to surgery is important for safe and efficient surgical practice and has been shown to improve overall mortality. This narrative review provides a summary of the current data with recommendations focusing on four key points.
Collapse
Affiliation(s)
- Stuart Allyn
- Resident, Department of Oral & Maxillofacial Surgery, University of Washington, Seattle, WA
| | - Nathalie Bentov
- Pre-anesthesia Clinic Medical Director, Harborview Medical Center, Department of Family Medicine, University of Washington, Seattle, WA
| | - Jasjit Dillon
- Professor & Program Director, Department of Oral & Maxillofacial Surgery, University of Washington, Chief of Service, Harborview Medical Center, Seattle, WA.
| |
Collapse
|
6
|
Fanning JP, Campbell BCV, Bulbulia R, Gottesman RF, Ko SB, Floyd TF, Messé SR. Perioperative stroke. Nat Rev Dis Primers 2024; 10:3. [PMID: 38238382 DOI: 10.1038/s41572-023-00487-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/23/2024]
Abstract
Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.
Collapse
Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- The George Institute for Global Health, Sydney, New South Wales, Australia.
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Sang-Bae Ko
- Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Thomas F Floyd
- Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
7
|
Khalid SI, Mirpuri P, Chilakapati S, Kwak A, Mitchell D, Adogwa O, Mehta AI. The Impact of Preoperative Antithrombotic Therapy on the Risks for Thrombo-ischemic Events and Bleeding among Patients Undergoing Elective Spine Surgery. Asian Spine J 2023; 17:1082-1088. [PMID: 38050357 PMCID: PMC10764144 DOI: 10.31616/asj.2023.0125] [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] [Received: 04/18/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 12/06/2023] Open
Abstract
STUDY DESIGN Retrospective matched analysis. PURPOSE To evaluate the effect of antithrombotic drug therapy on the rates of thrombo-ischemic or bleeding events 90 days following elective spine surgery. OVERVIEW OF LITERATURE Thrombo-ischemic and bleeding complications in patients undergoing spine surgery are major causes of morbidity. Many patients who pursue elective spine surgery are concurrently receiving antithrombotic therapy for unrelated conditions; however, at this time, the effects of preoperative antithrombotic use on postoperative bleeding and thrombosis are unclear. METHODS Using an all-payer claims database, patients who underwent elective cervical and lumbar spine interventions between January 1, 2010, and June 30, 2018, were identified. Individuals were categorized into groups taking and not taking antithrombotics. A 1:1 analysis was constructed based on comorbidities found to be independently associated with bleeding or ischemic complications using logistic regression models. The primary outcomes were the rates of thrombo-ischemic events and bleeding complications. RESULTS A total of 660,866 patients were eligible for inclusion. Following the matching procedure, 56,476 patient records were analyzed, with 28,238 in each group. The antithrombotic agent group had significantly greater odds of developing any 90-day thromboischemic event after surgery: deep vein thrombosis (odds ratio [OR], 3.61; 95% confidence interval [CI], 3.06-4.25), pulmonary embolism (OR, 3.93; 95% CI, 3.34-4.62), myocardial infarction (OR, 6.20; 95% CI, 5.69-6.76), and ischemic stroke (OR, 3.76; 95% CI, 3.31-4.27). In addition, the antithrombotic agent group had an increased likelihood of experiencing hematoma (OR, 1.54; 95% CI, 1.35-1.76) and need for transfusion (OR, 2.61; 95% CI, 2.29-2.96). CONCLUSIONS Patients taking antithrombotic medications before elective surgery of the cervical and lumbar spine had increased risks of both ischemic and bleeding events. Spine surgeons should carefully consider these implications when appraising patients for surgery, given the lack of guidelines on perioperative management of antithrombotic agents.
Collapse
Affiliation(s)
- Syed I. Khalid
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL,
USA
| | - Pranav Mirpuri
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL,
USA
| | - Sai Chilakapati
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX,
USA
| | - Angelika Kwak
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL,
USA
| | - Devon Mitchell
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL,
USA
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Cincinnati School of Medicine, Cincinnati, OH,
USA
| | - Ankit I. Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL,
USA
| |
Collapse
|
8
|
Nakamura K, Nagai M, Matsumoto I, Satoi S, Motoi F, Kawai M, Hosouchi Y, Higuchi R, Mizuno S, Ohtsuka T, Akahoshi K, Hakamada K, Unno M, Yamaue H, Nakamura M, Endo I, Sho M. Impact of antithrombotic therapy on postpancreatectomy hemorrhage in 7116 patients: A project study by the Japanese Society of Hepato-Biliary-Pancreatic Surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1161-1171. [PMID: 37658660 DOI: 10.1002/jhbp.1349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/07/2023] [Accepted: 05/16/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND We previously reported an association between antithrombotic therapy and an increased risk of postpancreatectomy hemorrhage (PPH). To validate our findings, we conducted a large-scale multicenter retrospective study from 63 high-volume centers in Japan. METHODS Between 2015 and 2018, 7116 patients who underwent pancreatectomy were enrolled. The antithrombotic group consisted of 920 patients (12.9%) who received preoperative antithrombotic agents including aspirin, clopidogrel, ticlopidine, prasugrel, warfarin, and direct oral anticoagulants. RESULTS PPH occurred in 235 (3.3%) of the patients. The incidence of PPH and mortality were significantly higher in the antithrombotic group than in the control group (5.7 vs. 3.0% and 2.2 vs. 0.9%, respectively; both p < .001). In multivariate analysis, a history of antithrombotic use was an independent risk factor for grade C PPH (p = .036). In the antithrombotic group, PPH tended to be delayed in the patients with restarting antithrombotic therapy. Notably, the occurrence of delayed PPH after restarting antithrombotic therapy was observed only when antithrombotic therapy was restarted within 10 days after pancreatectomy. CONCLUSIONS This multicenter study demonstrated that a history of antithrombotic use was a significant risk factor for PPH and mortality. In particular, the resumption of antithrombotic therapy in the early postoperative period should be done with caution.
Collapse
Affiliation(s)
- Kota Nakamura
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Fuyuhiko Motoi
- Department of Surgery, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasuo Hosouchi
- Department of Surgery, Gunma Saiseikai Maebashi Hospital, Maebashi, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Keiichi Akahoshi
- Department of Hepatobiliary-Pancreatic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Project Committee, Japanese Society of Hepato-Biliary-Pancreatic Surgery, Tokyo, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| |
Collapse
|
9
|
Xu Z, Zhao Y, Fu X, Hu W, Zhao C, Ge C, Ye H, Chen C. Laparoscopic versus Open Inguinal Hernia Repair in Aging Patients: A Propensity Score Matching-Based Retrospective Study. Ther Clin Risk Manag 2023; 19:657-666. [PMID: 37575687 PMCID: PMC10422990 DOI: 10.2147/tcrm.s423307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/02/2023] [Indexed: 08/15/2023] Open
Abstract
Objective Although laparoscopic repair has been widely carried out and promoted due to its minimally invasive advantages, open surgery is still popular compared to elderly patients. This study aims to compare the outcomes of laparoscopic (LIHR) vs open repair of inguinal hernias (OIHR) in elderly patients. Methods A retrospective analysis of the database was performed to identify elderly patients, from January 2021 through December 2022, who underwent surgery for an inguinal hernia. After a 1:1 propensity score matching (PSM) with a caliper of 0.1 was conducted to balance potential bias, binary logistic regressions were used for categorical and continuous outcomes. Results After PSM, 78 pairs of elderly patients were enrolled in this study, and there were no significant differences in baseline between LIHR and OIHR groups. Compared to OIHR, univariable and multivariable logistic regression analysis showed that LIHR was independently affected for reducing intraoperative hemorrhage (OR = 0.06, 95% CI: 0.02-0.18, P < 0.001) and shortening postoperative hospitalization time (OR = 0.29, 95% CI: 0.15-0.57, P < 0.001) in elderly patients. Furthermore, LIHR (OR = 0.28, 95% CI: 0.14-0.57, P < 0.001) and age (OR = 0.89, 95% CI: 0.82-0.96, P = 0.002) were independent affecting factors for relieving postoperative pain. Meanwhile, no obvious differences were detected in postoperative complications [LIHR 7.7% (6/78) vs OIHR 14.1% (11/78), P = 0.199]. Conclusion LIHR was closely associated with reducing intraoperative hemorrhage and shortening postoperative hospitalization time. Whilst LIHR and age were independently affecting factors for relieving postoperative pain.
Collapse
Affiliation(s)
- Zipeng Xu
- Department of General Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, 214105, People’s Republic of China
| | - Yong Zhao
- Department of General Surgery, Wuxi Rehabilitation Hospital, Wuxi, 214007, People’s Republic of China
| | - Xu Fu
- Department of General Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical school, Nanjing, 210008, People’s Republic of China
| | - Weidong Hu
- Department of General Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, 214105, People’s Republic of China
| | - Chunlong Zhao
- Department of General Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, 214105, People’s Republic of China
| | - Chen Ge
- Department of General Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, 214105, People’s Republic of China
| | - Hui Ye
- Department of Anesthesiology, ZhongDa Hospital, Southeast University, Nanjing, 210009, People’s Republic of China
- Department of Immunology, Ophthalmology & ORL, Complutense University School of Medicine, Madrid, 28040, Spain
| | - Chaobo Chen
- Department of General Surgery, Xishan People’s Hospital of Wuxi City, Wuxi, 214105, People’s Republic of China
- Department of General Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical school, Nanjing, 210008, People’s Republic of China
- Department of Immunology, Ophthalmology & ORL, Complutense University School of Medicine, Madrid, 28040, Spain
| |
Collapse
|
10
|
Gallant GG, Matzon JL, Beredjiklian PK, Rivlin M. Perioperative Management of Oral Anticoagulants and Antiplatelet Therapy in Hand and Wrist Surgery. J Am Acad Orthop Surg 2023; 31:820-833. [PMID: 37478048 DOI: 10.5435/jaaos-d-22-00751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 05/05/2023] [Indexed: 07/23/2023] Open
Abstract
There is wide variability in the management of patients on antithrombotic therapy requiring surgery of the hand and wrist. There are no specific guidelines regarding whether to temporarily cease or continue oral anticoagulants and antiplatelet agents. Discontinuation of these medications before surgery can lead to perioperative thromboembolic or ischemic events. On the other hand, continuation can lead to intraoperative or postoperative bleeding complications. This review discusses various anticoagulants and antiplatelet agents with special considerations for their management, analyzes the current literature, summarizes current recommendations, and provides direction for additional research.
Collapse
Affiliation(s)
- Gregory G Gallant
- From the Hand Surgeon Rothman Orthopaedics, Thomas Jefferson University Rothman Orthopaedics, Sidney Kimmel Medical College, Philadelphia, PA
| | | | | | | |
Collapse
|
11
|
Meinig R, Jarvis S, Salottolo K, Nwafo N, McNair P, Harrison P, Morgan S, Duane T, Woods B, Nentwig M, Kelly M, Cornutt D, Bar-Or D. Propensity matched analysis examining the effect of passive reversal of direct oral anticoagulants on blood loss and the need for transfusions among traumatic geriatric hip fractures. Eur J Med Res 2023; 28:241. [PMID: 37475008 PMCID: PMC10360353 DOI: 10.1186/s40001-023-01053-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/08/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Reversal of direct oral anticoagulants (DOACs) is currently recommended prior to emergent surgery, such as surgical intervention for traumatic geriatric hip fractures. However, reversal methods are expensive and timely, often delaying surgical intervention, which is a predictor of outcomes. The study objective was to examine the effect of DOAC reversal on blood loss and transfusions among geriatric patients with hip fractures. METHODS This retrospective propensity-matched study across six level I trauma centers included geriatric patients on DOACs with isolated fragility hip fractures requiring surgical intervention (2014-2017). Outcomes included: intraoperative blood loss, intraoperative pRBCs, and hospital length of stay (HLOS). RESULTS After matching there were 62 patients (31 reversed, 31 not reversed), 29 patients were not matched. The only reversal method utilized was passive reversal (waiting ≥ 24 hours for elimination). Passively reversed patients had a longer time to surgery (mean, 43 vs. 18 hours, p < 0.01). Most patients (92%) had blood loss (90% passively reversed, 94% not reversed); the median volume of blood loss was 100 mL for both those groups, p = 0.97. Thirteen percent had pRBCs transfused (13% passively reversed and 13% not reversed); the median volume of pRBCs transfused was 525 mL for those passively reversed and 314 mL for those not reversed, p = 0.52. The mean HLOS was significantly longer for those passively reversed (7 vs. 5 days, p = 0.001). CONCLUSIONS Passive DOAC reversal for geriatric patients with isolated hip fracture requiring surgery may be contributing to delayed surgery and an increased HLOS without having a significant effect on blood loss or transfusions. These data suggest that passive DOAC reversal may not be necessary prior to surgical repair of isolated hip fracture.
Collapse
Affiliation(s)
- Richard Meinig
- Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO, 80907, USA
| | - Stephanie Jarvis
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Kristin Salottolo
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Nnamdi Nwafo
- Swedish Medical Center, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Patrick McNair
- St. Anthony Hospital, 11600 W 2nd Plaza, Lakewood, CO, 80228, USA
| | - Paul Harrison
- Wesley Medical Center, 550 North Hillside St. Wichita, Wichita, KS, 67214, USA
| | - Steven Morgan
- Swedish Medical Center, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Therese Duane
- Medical City Plano, 3901 West 15th Street, Plano, TX, 75075, USA
| | - Bradley Woods
- Research Medical Center, 2316 East Meyer Blvd, Kansas City, MO, 64132, USA
| | - Michelle Nentwig
- Wesley Medical Center, 550 North Hillside St. Wichita, Wichita, KS, 67214, USA
| | - Michael Kelly
- Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO, 80907, USA
| | - David Cornutt
- Regional West Medical Center, 4021 Ave B, Scottsbluff, NE, 69361, USA
| | - David Bar-Or
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA.
| |
Collapse
|
12
|
Verhoeff K, Connell M, Shapiro AJ, Strickland M, Bigam DL, Anantha RV. Rate of prophylactic anti-Xa achievement and impact on venous thromboembolism following oncologic hepato-pancreatico-biliary surgery: A prospective cohort study. Am J Surg 2023; 225:1022-1028. [PMID: 36526454 DOI: 10.1016/j.amjsurg.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/23/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepato-pancreatico-biliary (HPB) patients experience competing risk of venous thromboembolism (VTE) and bleeding. We sought to evaluate the effect of anti-Xa levels on VTE and bleeding, and to characterize factors associated with subprophylaxis. METHODS This prospective cohort study evaluated adult HPB surgical patients; cohorts were described by anti-Xa levels as subprophylactic (<0.2 IU/mL), prophylactic (0.2-0.5 IU/mL), and supraprophylactic (>0.5 IU/mL). Primary outcome evaluated bleeding and VTE complications. Secondary outcomes evaluated factors associated with subprophylaxis. RESULTS We included 157 patients: 68 (43.6%) attained prophylactic anti-Xa and 89 (56.7%) were subprophylactic. Subprophylactic patients experienced more VTE compared to prophylactic patients (6.9% vs 0%; p = 0.028) without differences in bleeding complications (14.6% vs 5.9%; p = 0.081). Factors associated with subprophylactic anti-Xa included female sex (OR 2.90, p = 0.008), and Caprini score (OR 1.30, p = 0.035). Enoxaparin was protective against subprophylaxis compared to tinzaparin (OR 0.43, p = 0.029). CONCLUSIONS Many HPB patients have subprophylactic anti-Xa levels, placing them at risk of VTE. Enoxaparin may be preferential, however, studies evaluating optimized prophylaxis are needed.
Collapse
Affiliation(s)
- Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Matthew Connell
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Am James Shapiro
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Matt Strickland
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - David L Bigam
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Ram V Anantha
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
13
|
Statman BJ. Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery: Part 2. Anesth Prog 2023; 70:37-48. [PMID: 36995961 PMCID: PMC10069535 DOI: 10.2344/anpr-70-01-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/27/2023] [Indexed: 03/31/2023] Open
Abstract
Part 1 of "Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery" covered the physiological process of hemostasis and the pharmacology of both traditional and novel oral antiplatelets and anticoagulants. Part 2 of this review discusses various factors that are considered when developing a perioperative management plan for patients on oral antithrombotic therapy in consultation with dental professionals and managing physicians. Additionally included are how thrombotic and thromboembolic risks are assessed as well as how patient- and procedure-specific bleeding risks are evaluated. Special attention is given to the bleeding risks associated with procedures encountered when providing sedation and general anesthesia within the office-based dental environment.
Collapse
|
14
|
Targeted next-generation sequencing of genes involved in Warfarin Pharmacodynamics and pharmacokinetics pathways using the Saudi Warfarin Pharmacogenetic study (SWAP). THE PHARMACOGENOMICS JOURNAL 2023:10.1038/s41397-023-00300-3. [PMID: 36739459 DOI: 10.1038/s41397-023-00300-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 01/15/2023] [Accepted: 01/26/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND Warfarin is an oral anticoagulant commonly used for treatment and prophylaxis against thromboembolic events. Warfarins's narrow therapeutic index window is one of the main challenges in clinical practice; thus, it requires frequent monitoring and dose adjustment to maintain patients' therapeutic range. Warfarin dose variation and response are attributed to several inter-and intra-individuals factors, including genetic variants in enzymes involved in warfarin pharmacokinetics (PK) and pharmacodynamics (PD) pathways. Thus, we aim to utilize the next-generation sequencing (NGS) approach to identify rare and common genetic variants that might be associated with warfarin responsiveness. METHOD AND RESULTS A predesigned NGS panel that included 16 genes involved in Warfarin PK/PD pathways was used to sequence 786 patients from the Saudi Warfarin Pharmacogenetic Cohort (SWAP). Identified variants were annotated using several annotation tools to identify the pathogenicity and allele frequencies of these variants. We conducted variants-level association tests with warfarin dose. We identified 710 variants within the sequenced genes; 19% were novel variants, with the vast majority being scarce variants. The genetic association tests showed that VKORC1 (rs9923231, and rs61742245), CYP2C9 (rs98332238, rs9332172, rs1057910, rs9332230, rs1799853, rs1057911, and rs9332119), CYP2C19 (rs28399511, and rs3758581), and CYP2C8 (rs11572080 and rs10509681) were significantly associated with warfarin weekly dose. Our model included genetics, and non-genetic factors explained 40.1% of warfarin dose variation. CONCLUSION The study identifies novel variants associated with warfarin dose in the Saudi population. These variants are more likely to be population-specific variants, suggesting that population-specific studies should be conducted before adopting a universal warfarin genotype-guided dosing algorithm.
Collapse
|
15
|
Perioperative Medication Management in Elective Plastic Surgery Procedures. J Craniofac Surg 2023; 34:1131-1136. [PMID: 36735455 DOI: 10.1097/scs.0000000000009183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Perioperative medication management is vital to maintain patient safety while under anesthesia, as well as to avoid postoperative complications. Plastic surgeons make daily decisions on whether to ask a patient to stop taking medication before their surgery. These important decisions can affect bleeding risk, wound healing, and interactions with anesthetics, which can range from minor to life-threatening. Current plastic surgery literature lacks a comprehensive review of perioperative medication management, with existing reports focusing on specific procedures and specific medication classes. METHODS A PubMed database search was conducted for articles through July 2021. The bibliographies of included studies were also examined for articles not acquired in the initial search queries. The authors included studies on medication usage and perioperative guidance in patients undergoing elective plastic surgery procedures. The authors excluded studies unrelated to plastic surgery and studies where the medications were used as an intervention. Abstracts, animal studies, studies involving the pediatric population, and book chapters were also excluded, as well as articles not published in English. RESULTS A total of 801 papers were identified by our search terms. After title and abstract screening, 35 papers were selected for full-text review. After full-text review, 20 papers were selected for inclusion, with an additional 6 papers from cited references added. Of the 26 papers, 6 papers discussed psychotropic drugs, 6 papers discussed medications affecting hemostasis, 4 papers discussed hormone-containing medications, 3 papers discussed antilipid medications, 2 papers discussed antihypertensive medications, 2 papers discussed herbal supplements, 1 paper discussed both psychotropic and herbal supplements, 1 paper discussed medications affecting wound healing, and 1 paper discussed rheumatologic medications. A summary of those recommendations was then compiled together. CONCLUSIONS The perioperative medication management in elective plastic surgery procedures remains a complex and multidisciplinary process. It is important to manage these patients in a case-by-case manner and to consult a specialist when necessary. Careful medication reconciliation is essential to decrease the likelihood of adverse outcomes and interactions with perioperative anesthetics.
Collapse
|
16
|
Ono S, Ishimaru M, Yokota I, Konishi T, Okada A, Ono Y, Matsui H, Itai S, Yonenaga K, Tonosaki K, Watanabe R, Hoshi K, Yasunaga H. Risk of post-extraction bleeding with direct oral anticoagulant compared with warfarin: Retrospective cohort study using large scale claims data in Japan. Thromb Res 2023; 222:24-30. [PMID: 36563522 DOI: 10.1016/j.thromres.2022.12.007] [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: 08/10/2022] [Revised: 11/22/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Comparative safety of direct oral anticoagulants vs. warfarin in patients undergoing tooth extraction remains unclear. We compared the incidence of post-extraction bleeding between patients taking warfarin and those taking direct oral anticoagulants (DOACs) using administrative claims data. MATERIALS AND METHODS We identified outpatients on anticoagulant therapy who underwent permanent tooth extraction between 2015 and 2020 and categorized them into the warfarin and DOAC groups based on medication prescribed within six months prior to tooth extraction. We used the overlap propensity score weighting method to balance the baseline characteristics between the groups and compared the incidence of post-extraction bleeding within seven days after tooth extraction. RESULTS Among 5253 eligible patients, those in the DOAC group (n = 3696) were older and less frequently prescribed antiplatelets than those in the warfarin group (n = 1557). The distribution of tooth extraction type and number of teeth extracted in a single procedure did not differ between the groups. The unadjusted incidences of post-extraction bleeding in the warfarin and DOAC groups were 35 (2.2 %) and 71 (1.9 %), respectively. Moreover, the overlap weighting analysis showed that the adjusted odds ratio of post-extraction bleeding in the DOAC group in comparison with that in the warfarin group was 0.84 (95 % confidence interval, 0.54-1.31). CONCLUSION The incidence of post-extraction bleeding in patients taking DOACs was comparable to that in patients taking warfarin. The findings suggest that dentists and physicians should exercise the same degree of caution when extracting teeth in patients on DOACs and those on warfarin in terms of post-extraction bleeding.
Collapse
Affiliation(s)
- Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Miho Ishimaru
- Department of Oral Health Promotion, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo 060-8638, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yosuke Ono
- Department of General Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Shunsuke Itai
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kazumichi Yonenaga
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kanata Tonosaki
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Rinji Watanabe
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kazuto Hoshi
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| |
Collapse
|
17
|
Surgical Pharmacy for Optimizing Medication Therapy Management Services within Enhanced Recovery after Surgery (ERAS ®) Programs. J Clin Med 2023; 12:jcm12020631. [PMID: 36675560 PMCID: PMC9861533 DOI: 10.3390/jcm12020631] [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: 11/07/2022] [Revised: 12/16/2022] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
Drug-related problems (DRPs) are common among surgical patients, especially older patients with polypharmacy and underlying diseases. DRPs can potentially lead to morbidity, mortality, and increased treatment costs. The enhanced recovery after surgery (ERAS) system has shown great advantages in managing surgical patients. Medication therapy management for surgical patients (established as "surgical pharmacy" by Guangdong Province Pharmaceutical Association (GDPA)) is an important part of the ERAS system. Improper medication therapy management can lead to serious consequences and even death. In order to reduce DRPs further, and promote the rapid recovery of surgical patients, the need for pharmacists in the ERAS program is even more pressing. However, the medication therapy management services of surgical pharmacy and how surgical pharmacists should participate in ERAS programs are still unclear worldwide. Therefore, this article reviews the main perioperative medical management strategies and precautions from several aspects, including antimicrobial agents, antithrombotic agents, pain medication, nutritional therapy, blood glucose monitoring, blood pressure treatment, fluid management, treatment of nausea and vomiting, and management of postoperative delirium. Additionally, the way surgical pharmacists participate in perioperative medication management, and the relevant medication pathways are explored for optimizing medication therapy management services within the ERAS programs. This study will greatly assist surgical pharmacists' work, contributing to surgeons accepting that pharmacists have an important role in the multidisciplinary team, benefitting medical workers in treating, counseling, and advocating for their patients, and further improving the effectiveness, safety and economy of medication therapy for patients and promoting patient recovery.
Collapse
|
18
|
Gogayeva OK, Rudenko ML, Nudchenko OO. The Occurrence of Thrombotic Complications Due to Combat Trauma Against the Background of the COVID-19 Pandemic. UKRAINIAN JOURNAL OF CARDIOVASCULAR SURGERY 2022. [DOI: 10.30702/ujcvs/22.30(04)/gr058-115121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
An important point in the provision of highly specialized cardiac surgical care for combat trauma is determination of the optimal time, method and volume of surgical intervention, taking into account the persisting threat of infection with the SARS-COV-2 virus and associated thrombotic complications.
The aim. To investigate the mechanism of development and methods of prevention of thrombotic complications resulting from combat trauma against the background of the COVID-19 pandemic.
Materials and methods. We analyzed clinical case of patient R., a 37-year-old soldier with a postinfarction thrombosed aneurysm of the left ventricle. The patient underwent standard clinical and laboratory tests, electrocardiography, echocardiography, coronary angiography, computed tomography of the chest, duplex scanning of carotid arteries, arteries and veins of the upper and lower extremities. It was established that 4 months ago, during a combat mission, the service-man received a mine-explosive injury, shrapnel wounds of lower extremities, multifragmentary fracture of the right ϐibula and a gunshot wound to the right chest. The causes of post-traumatic myocardial infarction are mine-explosive injury, intramural course of the left anterior descending artery, youngage, poorly developed collaterals of coronary arteries, long-term transportation during the stages of medical evacuation and post-traumatic stress disorder. A month ago, the patient was diagnosed with COVID-19, thromboembolism of the right main branch of the pulmonary artery, for which thrombolytic therapy was performed. Follow-up computed tomography showed the signs of thromboembolism of the pulmonary arteries. Ultrasound examination revealed thromboses of upper and lower limbs. Thrombotic complications against the background of combat polytrauma are the result of hypercoagulation, acute inϐlammation with the release of proinϐlammatory cytokines and damage of the endothelium. SARS-COV-2 infection triggers a state of hypercoagulation and creates additional conditions for the occurrence of arterial and venous thrombosis. Considering the nature of the thrombotic lesions, was made a decision to postpone the cardiosurgical intervention for 3 months.
Conclusions. Thrombotic complications are an urgent problem after combat trauma. COVID-19 is an additional risk factor for hypercoagulation and a reason for delaying elective cardiac surgery. Conducting an electrocardiography to the wounded, regardless of age, is crucial for timely diagnosis andtreatment of acute coronary events. It is important to initiate anticoagulant therapy after eliminating all possible sources of bleeding due to the high risk of thrombotic complications against the background of chest trauma and limb fractures.
Collapse
|
19
|
Yang J, Wang K, Han C, Liu Q, Zhang S, Wu J, Jiang P, Yang S, Guo R, Mo S, Yang Y, Zhang J, Liu Y, Cao Y, Wang S. Preoperative antiplatelet therapy may be a risk factor for postoperative ischemic complications in intracranial hemorrhage patients. Int J Neurosci 2022:1-7. [PMID: 36503400 DOI: 10.1080/00207454.2022.2157724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hemorrhage (ICH) patients are still at risk of postoperative ischemic complications (PICs) after surgery. In addition, the proportion of patients receiving antiplatelet therapy (APT) in ICH patients increased significantly with age. This study aims to evaluate the impact of preoperative antiplatelet therapy on PICs in ICH patients. METHODS This is a cohort study that retrospectively analyzed the data of ICH patients who underwent surgical treatment. PICs rate was compared between patients with preoperative ATP and those without preoperative ATP. Univariate and multivariate analyses were conducted to evaluate the impact of preoperative APT on PICs. In addition, Kaplan-Meier method was used for survival analysis and the impact of PICs on patients' postoperative outcomes was evaluated. RESULTS A total of 216 patients were included in this study. There were 47 patients (21.76%) with preoperative APT; 169 patients (78.24%) without preoperative APT. The incidence of PICs in the APT group was significantly higher when compared with that in the nAPT group (36.17% vs. 20.71%, p = 0.028<0.05). Furthermore, significant differences were both observed in multivariate analysis (p = 0.035<0.05) and survival analysis (log rank χ2 = 5.415, p = 0.020<0.05). However, there was no significant difference between the outcomes of patients suffering from PICs and that of patients not suffering from PICs (p = 0.377 > 0.05). CONCLUSIONS In conclusion, preoperative APT may be a risk factor for PICs in ICH patients undergoing surgical treatment significantly.
Collapse
Affiliation(s)
- Junhua Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Chao Han
- Qingdao Central Hospital Group, Qingdao, P. R. China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jiaming Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| |
Collapse
|
20
|
Balch JA, Neal D, Crippen C, Johnson-Mann CN, Read TE, Loftus TJ, Al-Mansour MR. Safety of laparoscopic inguinal hernia repair in the setting of antithrombotic therapy. Surg Endosc 2022; 36:9011-9018. [PMID: 35674797 DOI: 10.1007/s00464-022-09360-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 05/16/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION There are a paucity of data regarding the safety of laparoscopic inguinal hernia repair in patients on antiplatelet and anticoagulant therapy (APT/ACT). We aim to compare the postoperative outcomes of laparoscopic (LIHR) vs. open repair of inguinal hernias (OIHR) in patients on APT/ACT. METHOD We conducted a retrospective cohort study using the Vizient Clinical DataBase. We included adults receiving APT/ACT who underwent outpatient, elective, and primary inguinal hernia repair between 2017 and 2019. Subgroup analysis was performed on patients receiving aspirin, non-aspirin antiplatelet, and anticoagulant therapy. Mixed-effects logistic regression was used to assess both the effect of APT/ACT on the probability of receiving LIHR vs OIHR and their respective outcomes. RESULT A total of 142,052 repairs were included, of which 21,441 (15%) were performed on patients receiving APT/ACT. Mean age was 69 years (± 10.5) and 93% were male. 19% of hernias were bilateral. 40% of operations were performed at teaching hospitals. On multivariable analysis, patients on non-aspirin antiplatelet or anticoagulant therapy were more likely to receive an open procedure (Odds Ratio (OR) = 1.2; 95% Confidence Intervals (CI) [1.1, 1.4] and OR = 1.4; CI [1.3, 1.5], respectively). LIHR was associated with a lower rate of length of stay > 1 day (OR = 0.65; CI [0.5, 0.9]). Rates of 30-day postoperative hematoma, transfusions, stroke, myocardial infarction, deep venous thrombosis, pulmonary embolism, readmission, and emergency department visits were similar between the two operative approaches. CONCLUSION Patients on APT/ACT represent a substantial proportion of those undergoing inguinal hernia repair. Non-aspirin antiplatelet or anticoagulant therapy are independent predictors of choosing an open repair. Laparoscopic repair appears to be safe in patients receiving APT/ACT under current perioperative management patterns.
Collapse
Affiliation(s)
- Jeremy A Balch
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Dan Neal
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Cristina Crippen
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Crystal N Johnson-Mann
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Thomas E Read
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Tyler J Loftus
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Mazen R Al-Mansour
- Department of Surgery, University of Florida, PO Box 100108, Gainesville, FL, 32610-0108, USA.
| |
Collapse
|
21
|
Power M, Bentley C, Benesch C. Nurse's Role in Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery. J Perianesth Nurs 2022; 37:751-759.e1. [PMID: 35835636 DOI: 10.1016/j.jopan.2022.02.002] [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: 09/24/2021] [Revised: 02/01/2022] [Accepted: 02/05/2022] [Indexed: 01/28/2023]
Abstract
Perioperative nurses have the opportunity to play a key role in prevention and recognition of stroke in patients undergoing noncardiac, nonneurological surgery and may impact this potentially devastating complication. Effective nursing care of the older adult requires a specialized knowledge base. Scientific Statements are a cornerstone of the knowledge base that informs this care. This article summarizes the recently released American Heart Association/American Stroke Association Scientific Statement entitled: Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery and discusses the nurse's role in the care of this vulnerable patient population.
Collapse
Affiliation(s)
- Martha Power
- Retired, Former Stroke Coordinator, West Virginia University Medicine, Morgantown, WV.
| | - Claire Bentley
- Department of Anesthesiology, West Virginia University Medicine, Morgantown, WV
| | - Curtis Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
| |
Collapse
|
22
|
Wilson S, Chen X, Cronin M, Dengler N, Enker P, Krauss ES, Laberko L, Lobastov K, Obi AT, Powell CA, Schastlivtsev I, Segal A, Simonson B, Siracuse J, Wakefield TW, McAneny D, Caprini JA, Caprini JA. Thrombosis prophylaxis in surgical patients using the Caprini Risk Score. Curr Probl Surg 2022; 59:101221. [PMID: 36372452 DOI: 10.1016/j.cpsurg.2022.101221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
| | - Xialan Chen
- Beijing Shijitan Hospital, Capital Medical University, Beijing, P.R. China
| | - MaryAnne Cronin
- Department of Orthopedic Surgery, Syosset Hospital, Syosset, NY
| | - Nancy Dengler
- Department of Orthopedic Surgery, Syosset Hospital, Syosset, NY
| | - Paul Enker
- Zucker School of Medicine, Hofstra University, Uniondale, NY
| | - Eugene S Krauss
- Department of Orthopedic Surgery, Syosset Hospital, Syosset, NY
| | - Leonid Laberko
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Kirill Lobastov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Chloé A Powell
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Ayal Segal
- Department of Orthopedic Surgery, Syosset Hospital, Syosset, NY
| | - Barry Simonson
- Zucker School of Medicine, Hofstra University, Uniondale, NY
| | | | | | - David McAneny
- Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Joseph A Caprini
- Emeritus, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Chicago, IL
| | | |
Collapse
|
23
|
Lim K, Satkunasivam R, Nipper C, Xu J, Hsu E, Slawin JR, Roy T, Allenson KC, Kim MP, Barber SM, Ellis T, Akinsola O, Klaassen Z, Esnaola N, Ravi B, Jerath A, Wallis CJD. Association between isolated abnormal coagulation profile on transfusion following major surgery: A NSQIP analysis of individuals without bleeding disorders. Transfusion 2022; 62:2223-2234. [PMID: 36250486 DOI: 10.1111/trf.17146] [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: 08/04/2022] [Accepted: 08/28/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Preoperative coagulation screening for patients without bleeding disorders remains controversial. The combinatorial risk of INR, aPTT, and platelet count (PLT) abnormalities leading to bleeding requiring transfusion is not known in these patients. We examined the association between abnormal coagulation profile and the risk of transfusion following common elective surgery in patients without bleeding disorders. STUDY DESIGN AND METHODS We utilized the National Surgical Quality Improvement Program (NSQIP) database from 2004 to 2018 to identify patients without a history of bleeding disorders undergoing common 23 major elective procedures across 10 specialties. Multivariable logistic regression was used to assess the association between coagulation profile and bleeding requiring packed red blood cell transfusion intra-/post-operatively. RESULTS Of the 672,075 patients meeting inclusion criteria, 53.7% presented with normal coagulation profile preoperatively. Overall, 12.2% (n = 82,368) received transfusion. In the setting of normal aPTT/PLT, both Equivocal INR of 1.1-1.5 (aOR 1.41, 95% CI 1.38-1.44) and Abnormal INR of >1.5 (aOR 1.81, 95% CI 1.71-1.93) were significantly associated with an increased risk of transfusion. Equivocal (60-70) and Abnormal (>70) aPTT with normal INR/PLT did not demonstrate a comparable risk of transfusion. We observed a synergistic effect of combinatorial lab abnormalities on the risk of transfusion when both Abnormal INR/aPTT and Low PLT of <100,000 were present (aOR 5.18, 95% CI 3.04-8.84), compared to the effect of Abnormal INR/aPTT and normal/elevated PLT (aOR 1.90, 95% CI 1.48-2.45). DISCUSSION The preoperative presence of abnormal findings in INR or PLT was significantly associated with the risk of bleeding requiring transfusion during intraoperative and postoperative periods.
Collapse
Affiliation(s)
- Kelvin Lim
- Department of Urology, Houston Methodist Hospital, Houston, Texas, USA
| | - Raj Satkunasivam
- Department of Urology, Houston Methodist Hospital, Houston, Texas, USA.,Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas, USA
| | - Cole Nipper
- Texas A&M Health Science Center College of Medicine, Bryan, Texas, USA
| | - Jiaqiong Xu
- Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas, USA
| | - Enshuo Hsu
- Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas, USA
| | - Jeremy R Slawin
- Department of Urology, Houston Methodist Hospital, Houston, Texas, USA
| | - Trisha Roy
- Department of Vascular Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Kelvin C Allenson
- Department of Surgical Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Min P Kim
- Department of Thoracic Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Sean M Barber
- Department of Spine Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Taryn Ellis
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Olutiwa Akinsola
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zachary Klaassen
- Division of Urology, Medical College of Georgia-Augusta University, Augusta, Georgia, USA
| | - Nestor Esnaola
- Department of Surgical Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Bheeshma Ravi
- Department of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Angela Jerath
- Department of Anesthesiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Christopher J D Wallis
- Department of Urology, University of Toronto, Toronto, Ontario, Canada.,Department of Urology, Mount Sinai Hospital, Toronto, Ontario, Canada
| |
Collapse
|
24
|
Lasica R, Asanin M, Djukanovic L, Radovanovic N, Savic L, Polovina M, Stankovic S, Ristic A, Zdravkovic M, Lasica A, Kravic J, Perunicic J. Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application. Pharmaceuticals (Basel) 2022; 15:ph15091146. [PMID: 36145366 PMCID: PMC9501350 DOI: 10.3390/ph15091146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.
Collapse
Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Correspondence:
| | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nebojsa Radovanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Polovina
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Arsen Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | | | | | - Jelena Kravic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jovan Perunicic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| |
Collapse
|
25
|
Anteby R, Verdugo FL, Aaron DG, Polk HC, Qadan M. Perioperative Pharmacologic Prophylaxis of Venous Thromboembolism: A Professional Liability Analysis. J Surg Res 2022; 274:77-84. [DOI: 10.1016/j.jss.2021.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/19/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022]
|
26
|
Xu S, Bie ZX, Li YM, Li B, Peng JZ, Kong FL, Li XG. Computed tomography-guided microwave ablation for non-small cell lung cancer patients on antithrombotic therapy: a retrospective cohort study. Quant Imaging Med Surg 2022; 12:3251-3263. [PMID: 35655826 PMCID: PMC9131327 DOI: 10.21037/qims-21-1043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/14/2022] [Indexed: 10/05/2023]
Abstract
BACKGROUND For non-small cell lung cancer (NSCLC) patients on antithrombotic therapy who are treated with microwave ablation (MWA), the transient interruption of antithrombotic agents may increase the risk of thromboembolism, and continuation of antithrombotic agents may increase the risk of intraprocedural hemorrhage. This retrospective cohort study aimed to explore the safety of MWA in patients with NSCLC on antithrombotic therapy. METHODS A total of 572 patients with NSCLC (antithrombotic therapy group: n=84, Group A; control group: n=488, Group B) who received MWA were included. Antithrombotic agent use was suspended before MWA and resumed as soon as possible after MWA. Hemorrhagic (hemothorax and hemoptysis) and thromboembolic complications (pulmonary embolism, cerebral infarction, and angina) were compared. Logistic regression analyses were used to investigate the predictors of hemorrhagic complications after MWA. RESULTS Hemorrhagic complications occurred in 8 participants (9.5%) from Group A and 33 participants (6.8%) from Group B, and no statistically significant difference was found (P=0.365). There were 3 participants (0.5%) who developed thromboembolic complications, including 1 case (1.2%, 1/84) of pulmonary embolism in Group A, and 2 cases (0.4%, 2/488) of cerebral infarction or angina in Group B; no significant difference was found (P=0.923). In the subgroup analyses of Group A, no statistically significant difference of hemorrhagic (P>0.999) or thromboembolic complications (P>0.999) was found between patients who received and did not receive bridging anticoagulation with heparin. Logistic regression analyses revealed that direct contact of a tumor with vessels ≥2 mm was a predictor of hemorrhagic complications [hazard ratio (HR) =2.318; 95% confidence interval (CI): 1.215-4.420; P=0.011], while antithrombotic therapy was irrelevant. CONCLUSIONS With the appropriate cessation and resumption of antithrombotic agents, patients with NSCLC on antithrombotic therapy have comparable incidence rates of hemorrhagic and thromboembolic complications after MWA to those of patients who are not on antithrombotic therapy. Therefore, with appropriate cessation, MWA appears to generally be safe for NSCLC patients on antithrombotic therapy.
Collapse
Affiliation(s)
- Sheng Xu
- Department of Minimally Invasive Tumor Therapies Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhi-Xin Bie
- Department of Minimally Invasive Tumor Therapies Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuan-Ming Li
- Department of Minimally Invasive Tumor Therapies Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Li
- Department of Minimally Invasive Tumor Therapies Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Jin-Zhao Peng
- Department of Minimally Invasive Tumor Therapies Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Fan-Lei Kong
- Department of Minimally Invasive Tumor Therapies Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Guang Li
- Department of Minimally Invasive Tumor Therapies Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
27
|
Furrer MA, Abgottspon J, Huber M, Engel D, Löffel LM, Beilstein CM, Burkhard FC, Wuethrich PY. Perioperative continuation of aspirin, oral anticoagulants or bridging with therapeutic low-molecular-weight heparin does not increase intraoperative blood loss and blood transfusion rate in cystectomy patients: an observational cohort study. BJU Int 2022; 129:512-523. [PMID: 34585829 DOI: 10.1111/bju.15599] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/29/2021] [Accepted: 09/14/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To assess if uninterrupted anticoagulant agents' administration affects blood loss and blood transfusion during open radical cystectomy (RC) and urinary diversion. PATIENTS AND METHODS We conducted an observational single-centre cohort study of a consecutive series of 1430 RC patients, between 2000 and 2020. Blood loss was depicted according to body weight and duration of surgery (mL/kg/h), and blood transfusion. The group 'with anticoagulant agents' was considered if surgery was performed with uninterrupted low-dose aspirin (ASS), oral anticoagulants (OAC) with an international normalised ratio (INR) goal of 2-2.5 or bridging with therapeutic low-molecular-weight heparin (LMWH). Outcomes were intraoperative blood loss, blood transfusion rate (separately analysed if administered within 24 h perioperatively or >24 h after surgery) and the 90-day major adverse cardiac events (MACE) rate. We used propensity score (PS)-matching analysis to adjust for imbalances between groups with or without anticoagulant agents. RESULTS The PS-matched median (interquartile range [IQR]) blood loss was 2.10 (1.50-2.94) mL/kg/h in patients with anticoagulant agents vs 2.11 (1.47-2.94) mL/kg/h without anticoagulant agents (Padj > 0.99). The PS-matched blood transfusion rates were 26.2% vs 35.1% (Padj = 0.875) within 24 h perioperatively and 57.0% vs 55.0% (Padj = 0.680) if administered >24 h postoperatively. A sub-analysis of the three different anticoagulant agents could not detect any significance between ASS, OAC, or LMWH. The PS-matched incidence of MACE was 9.1% in the group with anticoagulant agents and 8.1% in those without anticoagulant agents (Padj > 0.99). Limitations include selection bias and retrospective analysis from prospectively assessed data. CONCLUSIONS Perioperative continuation of ASS, uninterrupted OAC with low INR goal or bridging with LMWH had no impact on blood loss and transfusion rate in RC patients. Therefore, there might be no compulsory need for discontinuation of anticoagulant agents.
Collapse
Affiliation(s)
- Marc A Furrer
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Janine Abgottspon
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas M Löffel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian M Beilstein
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fiona C Burkhard
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
28
|
Briete LD, Towers WF, Bone R, Nair R, Steck M, Cutshall BT, Shah SP. Perioperative Anticoagulation Management. Crit Care Nurs Q 2022; 45:119-131. [PMID: 35212652 DOI: 10.1097/cnq.0000000000000395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Management of anticoagulation in individuals undergoing operative procedures is a complex situation. Each case should be assessed individually with proper risk assessment, monitoring, and plan for perioperative and postoperative anticoagulation. Clinical evidence for the management of these patients is relatively scarce, and clinicians are often assessing each individual case with minimal guidance. This review provides nurses with a summary of available literature on the assessment, laboratory monitoring, timing of adjusting anticoagulation, and bridging prior to procedures. In addition to general perioperative anticoagulation management, this review discusses perioperative management in special populations and provides a summary on principles when anticoagulation should be resumed following a procedure.
Collapse
Affiliation(s)
- Lauren D Briete
- Department of Pharmacy, Mississippi Baptist Medical Center, Jackson (Dr Briete); Department of Pharmacy, MD Anderson Cancer Center, Houston, Texas (Dr Towers); Department of Pharmacy, Methodist University Hospital, Memphis, Tennessee (Drs Bone and Cutshall); Department of Cardiothoracic Surgery, Stanford Healthcare, Stanford, California (Mr Nair); Department of Pharmacy, Indiana University Health Arnett Hospital, Lafayette (Dr Steck); and Department of Pharmacy, Mercy Health, Janesville, Wisconsin (Dr Shah)
| | | | | | | | | | | | | |
Collapse
|
29
|
Müssig K, Adamek HE. Adjustment of Anti-Hyperglycaemic Agents During Bowel Preparation for Colonoscopy in Patients with Diabetes. Exp Clin Endocrinol Diabetes 2022; 130:627-632. [PMID: 35359009 DOI: 10.1055/a-1782-9389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
OBJECTIVE Due to the growing diabetes pandemic, the number of colonoscopies performed in patients with diabetes is steadily rising. However, recommendations on adjustments of anti-hyperglycaemic agents (AHG) during bowel preparation for colonoscopy are limited. METHODS A total of nine articles were revealed on a PubMed search using the search terms "diabetes" and "colonoscopy", "sigmoidoscopy", "endoscopy", "endoscopic intervention", "endoscopic invasive diagnostics", "endoscopic surgery", or "diabetes care in the hospital" and manual screening of the references of the articles reporting on AHG adjustment during bowel preparation. RESULTS Regular glucose measurements and the opportunity to contact the diabetes team were commonly advised. Recommendations also agreed that all oral AHG and short-acting insulin should be omitted when patients are on clear fluids. Recent studies suggest discontinuation of sodium-glucose cotransporter-2 (SGLT2) inhibitors even three days before the colonoscopy. In contrast, recommendations differed regarding adjustment of basal insulin depending on diabetes type and time point in relation to the intervention. CONCLUSIONS While discontinuation of oral AHG and short-acting insulin during bowel preparation for colonoscopy is generally accepted, recommendations on the adaptation of basal insulin follow different approaches.
Collapse
Affiliation(s)
- Karsten Müssig
- Department of Internal Medicine, Gastroenterology and Diabetology, Niels Stensen Hospitals, Franziskus Hospital Harderberg, Georgsmarienhütte, Germany
| | - Henning E Adamek
- Second Department of Internal Medicine (Gastroenterology, Hepatology, Diabetology), Klinikum Leverkusen, Leverkusen, Germany
| |
Collapse
|
30
|
Wu F, Ma K, Xiang R, Han B, Chang J, Zuo Z, Luo Y, Mao M. Efficacy and safety of a bridging strategy that uses intravenous platelet glycoprotein receptor inhibitors for patients undergoing surgery after coronary stent implantation: a meta-analysis. BMC Cardiovasc Disord 2022; 22:125. [PMID: 35331138 PMCID: PMC8953042 DOI: 10.1186/s12872-022-02563-3] [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: 07/17/2021] [Accepted: 03/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current guidelines indicate we can consider a bridging strategy that uses intravenous, reversible glycoprotein inhibitors for patients that required surgery following recent stent implantation. However, no strong clinical evidence exists that demonstrates the efficacy and safety of this treatment. Therefore, in this study, the efficacy and safety of a bridging strategy that uses intravenous platelet glycoprotein receptor inhibitors will be evaluated. METHODS A meta-analysis was performed on preoperative bridging studies in patients undergoing coronary stent surgery. The primary outcome was the success rate of no major adverse cardiovascular events (MACE). The secondary outcomes were the success rate of no reoperations to stop bleeding. RESULTS A total of 10 studies that included 382 patients were used in this meta-analysis. For the primary endpoint, the success rate was 97.7% (95% CI 94.4-98.0%) for glycoprotein IIb/IIIa inhibitors, 98.8% (95% CI 96.0-100%) for tirofiban (6 studies) and 95.8% (95% CI 90.4-99.4%) for eptifibatide (4 studies). For secondary endpoints, the success rate was 98.0% (95% CI 94.8-99.9%) for glycoprotein IIb/IIIa inhibitors, 99.7% (95% CI 97.1-100%) for tirofiban (5 studies), and 95.3% (95% CI 88.5-99.4%) for eptifibatide (4 studies). CONCLUSION The results of this study showed that the use of intravenous platelet glycoprotein IIb/IIIa inhibitors as a bridging strategy might be safe and effective for patients undergoing coronary stent implantation that require surgery soon after.
Collapse
Affiliation(s)
- Fan Wu
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Kanghua Ma
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Rui Xiang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Baoru Han
- College of Medical Informatics, Chongqing Medical University, Chongqing, 401135, China
| | - Jing Chang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Zhong Zuo
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Yue Luo
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Min Mao
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China.
| |
Collapse
|
31
|
|
32
|
Wooten JM, Baldwin ST. Pharmacologic Agents Used to Reverse the Anticoagulant Effect of Common Anticoagulants. South Med J 2022; 115:220-226. [PMID: 35237842 DOI: 10.14423/smj.0000000000001372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Numerous oral and parenteral anticoagulant drugs are now available for clinical use. Understanding the precise pharmacologic properties of each anticoagulant is imperative for those practitioners who prescribe these drugs, including knowing the current recommendations for reversing the anticoagulant effect of each anticoagulant. This review provides a brief description of the various anticoagulants used today and also discusses the pharmacologic properties of those drugs used to reverse the anticoagulant action of specific anticoagulants.
Collapse
Affiliation(s)
- James M Wooten
- From the Department of Internal Medicine-Clinical Pharmacology, University of Missouri-Kansas City School of Medicine, Kansas City, and Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama (Retired)
| | - Steven T Baldwin
- From the Department of Internal Medicine-Clinical Pharmacology, University of Missouri-Kansas City School of Medicine, Kansas City, and Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama (Retired)
| |
Collapse
|
33
|
Liu Q, Li X, Wang N, Yang J, Wang K, Chen S, Li J, Wu J, Zhang Y, Wang S. A Novel Coagulation Classification and Postoperative Bleeding in Severe Spontaneous Intracerebral Hemorrhage Patients on Antiplatelet Therapy. Front Aging Neurosci 2022; 14:793129. [PMID: 35250539 PMCID: PMC8888928 DOI: 10.3389/fnagi.2022.793129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose For patients with severe spontaneous intracerebral hemorrhage on antiplatelet therapy (patients with APT-SICH), postoperative rebleeding (PR) is an important cause of poor outcomes after surgery. As impacted by coagulation disorder caused by APT, patients with APT-SICH are likely to suffer from PR. This study aimed to assess the risk of PR in patients with APT-SICH receiving emergency surgery using a novel coagulation classification. Methods This prospective, multicenter cohort study consecutively selected patients with APT-SICH between September 2019 and March 2021. The preoperative coagulation factor function was recorded, and the platelet function was assessed using thrombelastography. Based on platelet and coagulation factor function, a novel four-type coagulation classification, i.e., Type I (severe coagulation disorder), Type IIa (low platelet reserve capacity), Type IIb (normal coagulation), and Type III (hypercoagulation), was presented. The primary outcome was PR, defined as the rebleeding in the operative region or new intracerebral hemorrhage correlated with the operation. Results Of the included 197 patients with APT-SICH, PR occurred in 40 patients (20.3%). The novel coagulation classification categorized 28, 32, 122, and 15 patients into Type I, Type IIa, Type IIb, and Type III, respectively. The Type I patients had the highest incident rate of PR (39.3 per 100 persons), followed by the Type IIa patients (31.3 per 100 persons). In the PR-related analysis, the large hematoma volume (hazard ratio (HR): 1.02; 95% CI: 1.02–1.03; p < 0.001), Type I (HR: 9.72; 95% CI: 1.19–79.67; p = 0.034), and Type IIa (HR: 8.70; 95% CI: 1.09–69.61; p = 0.041) were correlated with the highest risk of PR. The coagulation classification could discriminate the PR patients from no PR (NPR) patients (p < 0.001), and it outperformed the conventional coagulation assessment (only considering platelet count and coagulation factor function) (c-statistic, 0.72 vs. 0.55). Conclusion The novel coagulation classification could discriminate the patients with APT-SICH with the highest risk of PR preoperatively. For the Type I and Type IIa patients, emergency surgery should be performed carefully.
Collapse
Affiliation(s)
- Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiong Li
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Nuochuan Wang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junhua Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shanwen Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiangan Li
- Department of Neurosurgery, Second People's Hospital of Wuxi City, Nanjing Medical University, Wuxi, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Jun Wu
| | - Yanan Zhang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Yanan Zhang
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- *Correspondence: Shuo Wang
| |
Collapse
|
34
|
Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
Collapse
Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Parrish RH, Findley R, Elias KM, Kramer B, Johnson EG, Gramlich L, Nelson GS. Pharmacotherapeutic prophylaxis and post-operative outcomes within an Enhanced Recovery After Surgery (ERAS®) program: A randomized retrospective cohort study. Ann Med Surg (Lond) 2022; 73:103178. [PMID: 35003725 PMCID: PMC8717452 DOI: 10.1016/j.amsu.2021.103178] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 12/11/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Pharmacotherapy prophylaxis embedded in Enhanced Recovery After Surgery (ERAS®) protocols is largely unknown because data related to agent choice, dosing, timing, and duration of treatment currently are not collected in the ERAS Interactive Audit System (EIAS®). This exploratory retrospective randomized cohort study characterized pharmacologic regimens pertaining to prophylaxis of surgical site infections (SSI), venous thromboembolism (VTE), and post-operative nausea and vomiting (PONV). MATERIALS AND METHODS The records of 250 randomly-selected adult patients that underwent elective colorectal (CR) and gynecologic/oncology procedures (GO) at an ERAS® site in North America were abstracted using REDCap. In addition to descriptive statistics, bivariate associations between categorical variables were compared. RESULTS Rates of SSI, VTE, & PONV were 3.3%, 1.1%, and 53.6%, respectively. Mean length of stay (LOS) for CR was 6.9 days and for GO, 3.5 days (p < 0.001). The most common antibiotic prophylaxis was one-time combination cefazolin 2 g and metronidazole 500 mg between 16 and 30 min preoperatively after chlorhexidine skin preparation. The most frequent VTE prophylaxis was tinzaparin 4500 units SC daily continued for at least 7 days after hospital discharge in oncology patients. PONV was related to longer LOS in both groups. Total morphine milligram equivalents (MME) was positively related to PONV and LOS in both CR & GO groups. CONCLUSION Guideline-consistent pharmacologic prophylaxis for SSI and VTE for both CR and GO patients was associated with low complication, LOS, and readmission rates. LOS in both groups was highly influenced by total MME, incidence of PONV and multi-modal anesthesia.
Collapse
Affiliation(s)
- Richard H. Parrish
- Department of Biomedical Sciences, Mercer University School of Medicine, 633 First Street, Columbus, GA, 31901, USA
- Corresponding author.;
| | - Rachelle Findley
- Department of Obstetrics and Gynecology, University of Calgary Cumming School of Medicine, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB T2N 1N4, Canada
| | - Kevin M. Elias
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Brian Kramer
- Department of Pharmacy Services, 111 South Grant Avenue, Grant Medical Center, Columbus, OH, 43215, USA
| | - Eric G. Johnson
- Department of Pharmacy Services, University of Kentucky, 1000 S. Limestone, First Floor, Lexington, KY, 40536, USA
| | - Leah Gramlich
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Walter C Mackenzie Health Sciences Centre, 8440 112 Street NW, Edmonton, AB T6G 2R7, Canada
| | - Gregg S. Nelson
- Department of Obstetrics and Gynecology, University of Calgary Cumming School of Medicine, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB T2N 1N4, Canada
| |
Collapse
|
36
|
Wang K, Liu Q, Wu J, Cao Y, Wang S. The role of monitoring platelet function perioperatively and platelet transfusion for operated spontaneous intracerebral hemorrhage patients with long-term oral antiplatelet therapy: A case report. Int J Surg Case Rep 2021; 89:106589. [PMID: 34844198 PMCID: PMC8636801 DOI: 10.1016/j.ijscr.2021.106589] [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: 09/08/2021] [Revised: 11/06/2021] [Accepted: 11/09/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction and importance Spontaneous intracerebral hemorrhage (SICH) with long-term oral antiplatelet therapy (LOAPT) is known as a dilemma in balancing the risk of postoperative rebleeding and ischemic events because of confused coagulation function. We herein describe a report of perioperative management of spontaneous intracerebral hemorrhage patient on long-term oral antiplatelet therapy. Case presentation A 42-year-old male patient on long-term oral antiplatelet therapy presented with coma, and he was diagnosed with spontaneous intracerebral hemorrhage. Considering the patient's clinical condition, despite the thromboelastography suggested that the inhibition of platelet function was high preoperatively, an emergency craniectomy were underwent. After platelet transfusion during surgery and taking control of the clotting and platelet function postoperatively, the patient was stable without rebleeding and new ischemic events in perioperative period and recovered satisfactorily. Clinical discussion Rare studies have provided evidence for managing operated spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet therapy, and whether platelet transfusion is recommended was controversial. In this case, we presented monitoring and taking control of clotting and platelet function postoperatively would help in preventing rebleeding and ischemic events in such patients; moreover, platelet transfusion may quickly and safely reverse platelet dysfunction for emergency surgery. This case was the first to report platelet function and coagulation function management in spontaneous intracerebral hemorrhage patients with long-term oral antiplatelet therapy. Conclusion Monitoring and maintaining coagulation and platelet function perioperatively are essential to balance the risk of postoperative rebleeding and ischemic events. Spontaneous intracerebral hemorrhage with antiplatelet therapy is known as a dilemma in postoperative management. Antiplatelet therapy may not be the absolute contraindication for surgery in the severe spontaneous intracerebral hemorrhage. It is essential to monitor and take control of platelet function in postoperative patients with antiplatelet therapy.
Collapse
Affiliation(s)
- Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100070, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100070, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100070, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100070, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100070, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China.
| |
Collapse
|
37
|
Abstract
Surgery and anesthesia carry risks of ischemic, hemorrhagic, hypoxic, and metabolic complications, all of which can result in neurologic symptoms and deficits. Patients with underlying cardiovascular and cerebrovascular risk factors are particularly vulnerable. In this article the authors review the neurologic complications of surgery and anesthesia, with a focus on the role of the neurologic consultant in preoperative evaluation and risk stratification and diagnosis and management of postoperative complications.
Collapse
Affiliation(s)
- Daniel Talmasov
- Department of Neurology, New York University School of Medicine, 222 East 41st Street, 14th Floor, New York, NY 10017, USA
| | - Joshua P Klein
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Room 4018, 60 Fenwood Road, Boston 02115, MA, USA.
| |
Collapse
|
38
|
Hada G, Zhang S, Song Y, Jaiswar M, Xie Y, Jian F, Lei W. Safety of Inguinal Hernia Repair in the Elderly with Perioperative Continuation of Antithrombotic Therapy. Visc Med 2021; 37:315-322. [PMID: 34540948 DOI: 10.1159/000509895] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/02/2020] [Indexed: 02/05/2023] Open
Abstract
Introduction This study aimed to evaluate the safety of an inguinal hernia repair (IHR) under local anesthesia (LA) in the elderly with a perioperative continuation of antithrombotic therapy (AT). Methods A total of 120 patients undergoing elective primary IHR between August 2018 and August 2019 at the West China Hospital of China were prospectively studied, among which 60 patients also had coexisting cardiovascular diseases and had a continuation of AT perioperatively (antithrombotic group); the other 60 patients were not on any prior AT (control group). The primary endpoints were intra- and postoperative hemorrhagic complications, the required interventions for complications based on the Clavien-Dindo classification, and postoperative thromboembolic complications. The secondary endpoints were nonhemorrhagic complications, intraoperative duration, and postoperative length of stay (LOS). Results None of the patients in both groups had significant intraoperative bleeding >10 mL, and there were no significant differences between the 2 groups in terms of the postoperative hemorrhagic complications: bruising (2 vs. 0%, p = 1.000), serosanguinous soakage (7 vs. 3%, p = 0.679), and no hematoma was observed. Interventions required for encountered complications based on the Clavien-Dindo classification grade I (7 vs. 5%, p = 1.000) were assessed. There were no episodes of postoperative thromboembolic complications within 60 days in both groups. There were also no significant differences between the 2 groups in terms of nonhemorrhagic complications, intraoperative duration, and postoperative LOS (p > 0.05 in all). Conclusions The perioperative continuation of AT did not increase the risk of intra- and postoperative hemorrhagic complications following IHR in the elderly. Thus, IHR under LA seems to be safe and feasible in this setting.
Collapse
Affiliation(s)
- Gonish Hada
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
| | - Sen Zhang
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yinghan Song
- Department of Day Care Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Mukesh Jaiswar
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yanyan Xie
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
| | - Fushan Jian
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wenzhang Lei
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
39
|
Fackelmayer OJ, Wu JX, Yeh MW. Endocrine Surgery: Management of Postoperative Complications Following Endocrine Surgery of the Neck. Surg Clin North Am 2021; 101:767-784. [PMID: 34537142 DOI: 10.1016/j.suc.2021.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cervical endocrine operations include parathyroidectomy, thyroid lobectomy, thyroidectomy, central neck dissection, and lateral neck dissection. The vital structures at risk include the recurrent laryngeal nerves to the intrinsic muscles of the larynx, additional cranial nerves, parathyroid glands essential for calcium homeostasis, aerodigestive structures, and great vessels. Here, the authors discuss complications of endocrine neck surgery, including cervical hematoma and other fluid collections, hypocalcemia from hypoparathyroidism, and nerve injuries, along with their prevention, mitigation, and management. Significant and permanent morbidity can result, but fortunately the overall rate of complications remains low, especially when surgery is performed by high-volume surgeons.
Collapse
Affiliation(s)
- Oliver J Fackelmayer
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, UCLA Endocrine Center, 100 Medical Plaza Driveway, Suite 310, Los Angeles, CA 90095, USA
| | - James X Wu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, UCLA Endocrine Center, 100 Medical Plaza Driveway, Suite 310, Los Angeles, CA 90095, USA
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, UCLA Endocrine Center, 100 Medical Plaza Driveway, Suite 310, Los Angeles, CA 90095, USA.
| |
Collapse
|
40
|
De Vincentis A, Behr AU, Bellelli G, Bravi M, Castaldo A, Galluzzo L, Iolascon G, Maggi S, Martini E, Momoli A, Onder G, Paoletta M, Pietrogrande L, Roselli M, Ruggeri M, Ruggiero C, Santacaterina F, Tritapepe L, Zurlo A, Antonelli Incalzi R. Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus. Aging Clin Exp Res 2021; 33:2405-2443. [PMID: 34287785 DOI: 10.1007/s40520-021-01898-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues. AIM To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF. METHODS A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence. RESULTS A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics). CONCLUSION These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.
Collapse
|
41
|
Yang J, Liu Q, Mo S, Wang K, Li M, Wu J, Jiang P, Yang S, Guo R, Yang Y, Zhang J, Liu Y, Cao Y, Wang S. The Effect of Preoperative Antiplatelet Therapy on Early Postoperative Rehemorrhage and Outcomes in Patients With Spontaneous Intracranial Hematoma. Front Aging Neurosci 2021; 13:681998. [PMID: 34276341 PMCID: PMC8283695 DOI: 10.3389/fnagi.2021.681998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose The effect of antiplatelet therapy (APT) on early postoperative rehemorrhage and outcomes of patients with spontaneous intracerebral hemorrhage (ICH) is still unclear. This study is to evaluate the effect of preoperative APT on early postoperative rehemorrhage and outcomes in ICH patients. Methods This was a multicenter cohort study. ICH patients undergoing surgery were divided into APT group and no antiplatelet therapy (nAPT) group according to whether patients received APT or not. Chi-square test, t-test, and Mann–Whitney U test were used to compare the differences in variables, postoperative rehematoma, and outcomes between groups. Multivariate logistics regression analysis was used to correct for confounding variables, which were different in group comparison. Results One hundred fifty ICH patients undergoing surgical treatment were consecutively included in this study. Thirty five (23.33%) people were included in the APT group, while 115 (76.67%) people were included in the nAPT group. The incidence of early postoperative rehemorrhage in the APT group was significantly higher than that in the nAPT group (25.7% VS 10.4%, p = 0.047 < 0.05). After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT had no significant effect on early postoperative rehemorrhage (p = 0.067). There was no statistical difference between the two groups in early poorer outcomes (p = 0.222) at 14 days after surgery. After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT also had no significant effect on early poorer modified Rankin Scale (mRS) (p = 0.072). Conclusion In conclusion, preoperative APT appears to be safe and have no significant effect on early postoperative rehematoma and outcomes in ICH patients.
Collapse
Affiliation(s)
- Junhua Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Maogui Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jiaming Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| |
Collapse
|
42
|
Ortiz RM, Golijanin B, O'Rourke TK, Sobel DW, Pillsbury L, T Tucci C, Caffery P, Golijanin D. Direct Oral Anticoagulants for Venous Thromboembolism Prophylaxis Following Robot-assisted Radical Cystectomy: A Retrospective Feasibility Study at a Single Academic Medical Center. Urology 2021; 156:154-162. [PMID: 34171347 DOI: 10.1016/j.urology.2021.04.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/11/2021] [Accepted: 04/15/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To evaluate the use of direct oral anticoagulants following radical cystectomy for venous thromboembolism prophylaxis. We compared the experience of those who received venous thromboembolism prophylaxis following a robot-assisted radical cystectomy with either a direct oral anticoagulant or enoxaparin. METHODS Medical records of 66 patients who underwent robot-assisted radical cystectomy between July 2017 and May 2020 at a single academic institution were reviewed retrospectively. Patients received extended prophylaxis with either a direct oral anticoagulant or enoxaparin before or following surgical discharge. Venous thromboembolic events and complications resulting in emergency department visits and readmissions were reviewed over a 90-day postoperative period. RESULTS A total of 4 venous thromboembolic events within 90 days of surgery were observed. Among patients taking enoxaparin, 5% (2/37) developed a deep vein thrombosis and 3% (1/37) developed a pulmonary embolism. Among patients taking direct oral anticoagulants, 3% (1/29) developed a deep vein thrombosis. Zero patients in the enoxaparin group and 3% (1/29) of patients in the direct oral anticoagulant group experienced bleeding that required an emergency department visit. CONCLUSION Direct oral anticoagulants performed comparably to enoxaparin in this feasibility study following robot-assisted radical cystectomy in 66 patients. No significant differences in the number of venous thromboembolisms or bleeding complications were observed. These data encourage future studies and support the prospect of direct oral anticoagulants as a potentially suitable oral alternative to injectable low molecular weight heparins for venous thromboembolism prophylaxis following radical cystectomy.
Collapse
Affiliation(s)
- Rebecca M Ortiz
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI
| | - Borivoj Golijanin
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI
| | - Timothy K O'Rourke
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - David W Sobel
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - Lauren Pillsbury
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI
| | - Christopher T Tucci
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - Philip Caffery
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI
| | - Dragan Golijanin
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI.
| |
Collapse
|
43
|
Udelsman BV, Soni M, Madariaga ML, Fintelmann FJ, Best TD, Li SSY, Chang DC, Gaissert HA. Incidence, aetiology and outcomes of major postoperative haemorrhage after pulmonary lobectomy. Eur J Cardiothorac Surg 2021; 57:462-470. [PMID: 31562514 DOI: 10.1093/ejcts/ezz266] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/19/2019] [Accepted: 08/30/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Post-lobectomy bleeding is uncommon and rarely studied. In this study, we aimed to determine the incidence of post-lobectomy haemorrhage and compare the outcomes of reoperation and non-operative management. METHODS We conducted a single-institution review of lobectomy cases from 2009 to 2018. The patients were divided into two groups based on the treatment for postoperative bleeding: reoperation or transfusion of packed red blood cells with observation. Transfusion correcting intraoperative blood loss was excluded. One or more criteria defined postoperative bleeding: (i) drop in haematocrit ≥10 or (ii) frank, sustained chest tube bleeding with or without associated hypotension. Covariates included demographics, comorbidities and operative characteristics. Outcomes were operative mortality, complications, length of hospital stay and readmission within 30 days. RESULTS Following 1960 lobectomies (92% malignant disease, 8% non-malignant), haemorrhage occurred in 42 cases (2.1%), leading to reoperation in 27 (1.4%), and non-operative management in 15 (0.8%). The median time to reoperation was 17 h. No source of bleeding was identified in 44% of re-explorations. Patients with postoperative haemorrhage were more often male (64.3% vs 41.2%; P < 0.01) and more likely to have preoperative anaemia (45.2% vs 26.5%; P = 0.01), prior median sternotomy (14.3% vs 6.0%; P = 0.04), an infectious indication (7.1% vs 1.8%; P = 0.01) and operative adhesiolysis (45.2% vs 25.8%; P = 0.01). Compared with non-operative management, reoperation was associated with fewer units of packed red blood cells transfusion (0.4 vs 1.9; P < 0.001), while complication rates were similar and 30-day mortality was absent in either group. CONCLUSIONS Haemorrhage after lobectomy is associated with multiple risk factors. Reoperation may avoid transfusion. A prospective study should optimize timing and selection of operative and non-operative management.
Collapse
Affiliation(s)
- Brooks V Udelsman
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA.,Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, MA, USA
| | - Monica Soni
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA.,Georgetown University School of Medicine, Washington, DC, USA
| | | | | | - Till D Best
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.,Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Selena Shi-Yao Li
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David C Chang
- Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, MA, USA
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
44
|
Abstract
Neurological complications after cardiac surgery and percutaneous cardiac interventions are not uncommon. These include periprocedural stroke, postoperative cognitive dysfunction after cardiac surgery, contrast-induced encephalopathy after percutaneous interventions, and seizures. In this article, we review the incidence, pathophysiology, diagnosis, and management of these complications. Improved understanding of these complications could lead to their prevention, faster detection, and facilitation of diagnostic workup and appropriate treatment.
Collapse
Affiliation(s)
| | - Jeffrey Wang
- Division of Neurology, Department of Medicine, University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Magdy Selim
- Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| |
Collapse
|
45
|
Challenges in Patient Blood Management for Cardiac Surgery: A Narrative Review. J Clin Med 2021; 10:jcm10112454. [PMID: 34205971 PMCID: PMC8198483 DOI: 10.3390/jcm10112454] [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: 03/31/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022] Open
Abstract
About 15 years ago, Patient Blood Management (PBM) emerged as a new paradigm in perioperative medicine and rapidly found support of all major medical societies and government bodies. Blood products are precious, scarce and expensive and their use is frequently associated with adverse short- and long-term outcomes. Recommendations and guidelines on the topic are published in an increasing rate. The concept aims at using an evidence-based approach to rationalize transfusion practices by optimizing the patient's red blood cell mass in the pre-, intra- and postoperative periods. However, elegant as a concept, the implementation of a PBM program on an institutional level or even in a single surgical discipline like cardiac surgery, can be easier said than done. Many barriers, such as dogmatic ideas, logistics and lack of support from the medical and administrative departments need to be overcome and each center must find solutions to their specific problems. In this paper we present a narrative overview of the challenges and updated recommendations for the implementation of a PBM program in cardiac surgery.
Collapse
|
46
|
Matsuoka T, Ichihara N, Shinozaki H, Kobayashi K, Lefor AK, Kimura T, Kitagawa Y, Kakeji Y, Miyata H, Sasaki J. Antithrombotic drugs have a minimal effect on intraoperative blood loss during emergency surgery for generalized peritonitis: a nationwide retrospective cohort study in Japan. World J Emerg Surg 2021; 16:27. [PMID: 34044868 PMCID: PMC8162009 DOI: 10.1186/s13017-021-00374-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/18/2021] [Indexed: 11/28/2022] Open
Abstract
Background The effect of antithrombotic drugs on intraoperative operative blood loss volume in patients undergoing emergency surgery for generalized peritonitis is not well defined. The purpose of this study was to investigate the effect of antithrombotic drugs on intraoperative blood loss in patients with generalized peritonitis using a nationwide surgical registry in Japan. Method This retrospective cohort study used a nationwide surgical registry data from 2011 to 2017 in Japan. Propensity score matching for the use of antithrombotic drugs was used for the adjustment of age, gender, comorbidities, frailty, preoperative state, types of surgery, surgical approach, laboratory data, and others. The main outcome was intraoperative blood loss: comparison of intraoperative blood loss, ratio of intraoperative blood loss after adjusted for confounding factors, and variable importance of all covariates. Results A total of 70,105 of the eligible 75,666 patients were included in this study, and 2947 patients were taking antithrombotic drugs. Propensity score matching yielded 2864 well-balanced pairs. The blood loss volume was slightly higher in the antithrombotic drug group (100 [10–349] vs 70 [10–299] ml). After adjustment for confounding factors, the use of antithrombotic drugs was related to a 1.30-fold increase in intraoperative blood loss compared to non-use of antithrombotic drugs (95% CI, 1.16–1.45). The variable importance revealed that the effect of the use of antithrombotic drugs was minimal compared with surgical approach or type of surgery. Conclusion This study shows that while taking antithrombotic drugs is associated with a slight increase in intraoperative blood loss in patients undergoing emergency surgery for generalized peritonitis, the effect is likely of minimal clinical significance. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00374-z.
Collapse
Affiliation(s)
- Tadashi Matsuoka
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinkjuku, Tokyo, 164-8582, Japan. .,Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan.
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Kenji Kobayashi
- Department of Surgery, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | | | - Toshimoto Kimura
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Yuko Kitagawa
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Yoshihiro Kakeji
- Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinkjuku, Tokyo, 164-8582, Japan
| |
Collapse
|
47
|
Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Bang Foss N, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott M. Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization. World J Surg 2021; 45:1272-1290. [PMID: 33677649 PMCID: PMC8026421 DOI: 10.1007/s00268-021-05994-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.
Collapse
Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology and Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620, Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Faculty of Life Sciences and Medicine, School of Population Health & Environmental Sciences, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Huddinge Hälsovägen 3. B85, S 141 86, Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Department of Surgery and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Jeniffer S. Kim
- Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital & School of Medical Sciences, Örebro University, 701 85 Örebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital / Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054 USA
| | - Michael Scott
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| |
Collapse
|
48
|
Joshi TV, Bruce SF, Grim R, Buchanan T, Chatterjee-Paer S, Burton ER, Sorosky JI, Shahin MS, Edelson MI. Implementation of an enhanced recovery protocol in gynecologic oncology. Gynecol Oncol Rep 2021; 36:100771. [PMID: 34036136 PMCID: PMC8134956 DOI: 10.1016/j.gore.2021.100771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/19/2021] [Accepted: 04/24/2021] [Indexed: 12/18/2022] Open
Abstract
Enhanced recovery in gynecologic oncology decreased narcotic usage. Shorter length of hospital stay was also observed in the ERAS cohort. ERAS produced early return of bowel function. The ERAS cohort received less perioperative blood transfusions. A compliance analysis is integral to successful implementation of ERAS.
Enhanced Recovery after Surgery (ERAS) is an evidence-based approach that aims to reduce narcotic use and maintain anabolic balance to enable full functional recovery. Our primary aim was to determine the effect of ERAS on narcotic usage among patients who underwent exploratory laparotomy by gynecologic oncologists. We characterized its effect on length of stay, intraoperative blood transfusions, bowel function, 30-day readmissions, and postoperative complications. A retrospective cohort study was performed at Abington Hospital-Jefferson Health in gynecologic oncology. Women who underwent an exploratory laparotomy from 2011 to 2016 for both benign and malignant etiologies were included before and after implementation of our ERAS protocol. Patients who underwent a bowel resection were excluded. A total of 724 patients were included: 360 in the non-ERAS and 364 in the ERAS cohort. An overall reduction in narcotic usage, measured as oral morphine milliequivalents (MMEs) was observed in the ERAS relative to the non-ERAS group, during the entire hospital stay (MME 34 versus 68, p < 0.001 and within 72 h postoperatively (MME 34 versus 60, p < 0.005). A shorter length of stay and earlier return of bowel function were also observed in the ERAS group. No differences in 30-day readmissions (p = 0.967) or postoperative complications (p = 0.328) were observed. This study demonstrated the benefits of ERAS in Gynecologic Oncology. A significant reduction of postoperative narcotic use, earlier return of bowel function and a shorter postoperative hospital stay was seen in the ERAS compared to traditional perioperative care.
Collapse
Affiliation(s)
- Tanvi V Joshi
- Department of Obstetrics and Gynecology, Abington Hospital-Jefferson Health, 1200 Old York Road, Price 109, Abington, PA 19001, United States
| | - Shaina F Bruce
- Department of Obstetrics and Gynecology, Abington Hospital-Jefferson Health, 1200 Old York Road, Price 109, Abington, PA 19001, United States
| | - Rod Grim
- Department of Obstetrics and Gynecology, Abington Hospital-Jefferson Health, 1200 Old York Road, Price 109, Abington, PA 19001, United States
| | - Tommy Buchanan
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
| | - Sudeshna Chatterjee-Paer
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
| | - Elizabeth R Burton
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
| | - Joel I Sorosky
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
| | - Mark S Shahin
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
| | - Mitchell I Edelson
- Hanjani Institute for Gynecologic Oncology, Asplundh Cancer Pavilion, Abington Hospital-Jefferson Health, 3941 Commerce Avenue, Willow Grove, PA 19090, United States
| |
Collapse
|
49
|
Bruzzone P, Bini F, Lancia M, Popivanov G, Giustozzi M, Marinozzi F, D'Andrea V, Cirocchi R. The role of computed tomography angiography 3D imaging in postoperative hemorrhage after groin mesh hernioplasty during anticoagulation therapy. Minerva Surg 2021; 76:286-287. [PMID: 33855375 DOI: 10.23736/s2724-5691.21.08704-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Paolo Bruzzone
- Paride Stefanini Department of General and Specialist Surgery, Sapienza University, Rome, Italy -
| | - Fabiano Bini
- Department of Mechanical and Aerospace Engineering, Sapienza University, Rome, Italy
| | - Massimo Lancia
- Department of General Surgery, Hospital of Terni, University of Perugia, Terni, Italy
| | - Georgi Popivanov
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - Michela Giustozzi
- Unit of Internal Vascular and Emergency Medicine and Stroke, University of Perugia, Perugia, Italy
| | - Franco Marinozzi
- Department of Mechanical and Aerospace Engineering, Sapienza University, Rome, Italy
| | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Roberto Cirocchi
- Department of General Surgery, Hospital of Terni, University of Perugia, Terni, Italy
| |
Collapse
|
50
|
Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messé SR, Mijalski C, Nelson MT, Power M, Welch BG. Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association. Circulation 2021; 143:e923-e946. [PMID: 33827230 DOI: 10.1161/cir.0000000000000968] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.
Collapse
|