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Quality of Life and Post-Surgical Complications in Patients on Chronic Antiplatelet Therapy with Proximal Femur Fracture: 12-Month Follow-Up after Implementing a Strategy to Shorten the Time to Surgery. J Clin Med 2023; 12:jcm12031130. [PMID: 36769778 PMCID: PMC9918231 DOI: 10.3390/jcm12031130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/25/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND We evaluated a strategy to shorten the time from admission to surgery in patients with proximal femur fractures on chronic antiplatelet therapy. We reported a 12-month follow-up on complications and quality of life (QoL). METHODS Multicentre, open-label, randomized, parallel clinical trial. Patients were randomized to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Medical and surgical complications and QoL (EQ-5D-5L questionnaire) were assessed during the hospital stay, and after hospital discharge at 30 days, and 6 and 12 months. RESULTS From 156 randomized patients, 143 patients underwent surgery. The mean age was 85.5 (7.8) years and 68.0% were female. After hospital discharge, 5.7% of patients had surgical wound complications and 55.9% had medical complications, with 42.7% having serious adverse events. QoL improved significantly after surgery, with the best scores at the six-month follow-up. The overall mortality was 32.2%. There were no differences between early and delayed surgery groups in any assessed outcomes. CONCLUSION It seems safe to reduce the time of surgery under neuraxial anaesthesia in patients with hip fractures on chronic antiplatelet therapy by platelet function testing. QoL in particular improves in the first six months after surgery.
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Ferrandis R, Cassinello C, Sierra P, Llau JV. "Letter to the Editor" response to Vives and Devereaux. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:373-374. [PMID: 35760693 DOI: 10.1016/j.redare.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 11/04/2021] [Indexed: 06/15/2023]
Affiliation(s)
- R Ferrandis
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, València, Spain.
| | - C Cassinello
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Pilar Sierra
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Fundació Puigvert, Barcelona, Spain
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Doctor Peset, València, Spain
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Montalvá E, Rodríguez-Perálvarez M, Blasi A, Bonanad S, Gavín O, Hierro L, Lladó L, Llop E, Pozo-Laderas JC, Colmenero J. Consensus Statement on Hemostatic Management, Anticoagulation, and Antiplatelet Therapy in Liver Transplantation. Transplantation 2022; 106:1123-1131. [PMID: 34999660 PMCID: PMC9128618 DOI: 10.1097/tp.0000000000004014] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anticoagulation and antiplatelet therapies are increasingly used in liver transplant (LT) candidates and recipients due to cardiovascular comorbidities, portal vein thrombosis, or to manage posttransplant complications. The implementation of the new direct-acting oral anticoagulants and the recently developed antiplatelet drugs is a great challenge for transplant teams worldwide, as their activity must be monitored and their complications managed, in the absence of robust scientific evidence. In this changing and clinically heterogeneous scenario, the Spanish Society of Liver Transplantation and the Spanish Society of Thrombosis and Haemostasis aimed to achieve consensus regarding the indications, drugs, dosing, and timing of anticoagulation and antiplatelet therapies initiated from the inclusion of the patient on the waiting list to post-LT surveillance. A multidisciplinary group of experts composed by transplant hepatologists, surgeons, hematologists, transplant-specialized anesthesiologists, and intensivists performed a comprehensive review of the literature and identified 21 clinically relevant questions using the patient-intervention-comparison-outcome format. A preliminary list of recommendations was drafted and further validated using a modified Delphi approach by a panel of 24 transplant delegates, each representing a LT institution in Spain. The present consensus statement contains the key recommendations together with the core supporting scientific evidence, which will provide guidance for improved and more homogeneous clinical decision making.
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Affiliation(s)
- Eva Montalvá
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Instituto de Investigación Sanitaria de La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Manuel Rodríguez-Perálvarez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Hepatology and Liver Transplantation, Reina Sofía University Hospital, IMIBIC, University of Córdoba, Córdoba, Spain
| | - Annabel Blasi
- Department of Anesthesiology, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Santiago Bonanad
- Unidad de Hemostasia y Trombosis, Servicio de Hematología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Olga Gavín
- Departamento de Hematología y Hemoterapia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Loreto Hierro
- Department of Liver Transplantation, Hospital Universitario La Paz, Madrid, Spain
| | - Laura Lladó
- Liver Transplant Unit, Department of Surgery, Bellvitge University Hospital, IDIBELL, University of Barcelona, Barcelona, Spain
| | - Elba Llop
- Department of Hepatology and Liver Transplantation, Reina Sofía University Hospital, IMIBIC, University of Córdoba, Córdoba, Spain
- Servicio de Aparato Digestivo, Instituto de Investigación Puerta de Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
| | | | - Jordi Colmenero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
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Martinez S, Giménez-Milà M, Cepas P, Anduaga I, Masotti M, Matute P, Castellà M, Sabaté M. Spontaneous Coronary Artery Dissection: Rediscovering an Old Cause of Myocardial Infarction. J Cardiothorac Vasc Anesth 2022; 36:3303-3311. [PMID: 35618587 DOI: 10.1053/j.jvca.2022.03.022] [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: 01/13/2022] [Revised: 02/28/2022] [Accepted: 03/21/2022] [Indexed: 11/11/2022]
Abstract
Spontaneous coronary artery dissection is an uncommon, but not insignificant cause of acute coronary syndrome that overwhelmingly affects middle-aged women. The pathophysiology of coronary dissection appears to be an outside-in mechanism, where the initiating event is not an intimal tear but rather the formation of an intramural hematoma, which compromises blood flow by reducing the arterial lumen. Considering this mechanism, it is clear to see how intracoronary imaging techniques, such as optical coherence tomography and intravascular ultrasound, are most accurate in the diagnosis. However, they carry a high rate of complications and are therefore generally avoided when the clinical scenario and angiographic appearance both support the diagnosis of spontaneous coronary artery dissection. The natural history of the disease is toward healing of the vessel wall and restoration of blood flow. Therefore, conservative medical management is the preferred approach unless there are high-risk factors such as hemodynamic instability, signs of ischemia and severe proximal or multivessel lesions, in which percutaneous or surgical revascularization should be considered. Perioperative evaluation of these patients must take into account several aspects of this disease. Most of these patients will be receiving single or dual antiplatelet therapy, so one must consider the timing of the event and the surgical hemorrhagic risk when deciding to stop these therapies. Extracoronary vascular disease also must be assessed because it can have an effect on patient monitoring and risk of postoperative complications.
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Affiliation(s)
- Samira Martinez
- Department of Anesthesia and Intensive Care, Hospital CLINIC de Barcelona, Barcelona, Spain
| | - Marc Giménez-Milà
- Department of Anesthesia and Intensive Care, Hospital CLINIC de Barcelona, Barcelona, Spain; Institut d'investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain.
| | - Pedro Cepas
- Institut d'investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain; Department of Cardiology, Hospital CLINIC de Barcelona, Barcelona, Spain
| | - Iñigo Anduaga
- Department of Cardiology, Hospital CLINIC de Barcelona, Barcelona, Spain
| | - Monica Masotti
- Institut d'investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain; Department of Cardiology, Hospital CLINIC de Barcelona, Barcelona, Spain
| | - Purificación Matute
- Department of Anesthesia and Intensive Care, Hospital CLINIC de Barcelona, Barcelona, Spain
| | - Manel Castellà
- Department of Cardiovascular Surgery and Transplantation, Hospital CLINIC de Barcelona, Barcelona, Spain
| | - Manel Sabaté
- Institut d'investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain; Department of Cardiology, Hospital CLINIC de Barcelona, Barcelona, Spain
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Early Surgery with Neuraxial Anaesthesia in Patients on Chronic Antiplatelet Therapy with a Proximal Femur Fracture: Multicentric Randomised Clinical Trial. J Clin Med 2021; 10:jcm10225371. [PMID: 34830654 PMCID: PMC8624584 DOI: 10.3390/jcm10225371] [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: 10/25/2021] [Revised: 11/14/2021] [Accepted: 11/16/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Patients with proximal femur fracture on antiplatelet treatment benefit from early surgery. Our goal was to perform early surgery under neuraxial anaesthesia when indicated by the platelet function test. Methods: We conducted a multicentre randomised open-label parallel clinical trial. Patients were randomised to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Early surgery was programmed when the functional platelet count (as measured by Plateletworks) was >80 × 109/L. The primary outcome was the emergency admission-to-surgery interval. Secondary outcomes were platelet function, postoperative bleeding, medical and surgical complications, and mortality. Results: A total of 156 patients were randomised, with 78 in each group, with a mean (SD) age of 85.96 (7.9) years, and 67.8% being female. The median (IQR) time to surgery was 2.3 (1.5–3.7) days for the experimental group and 4.9 (4.4–5.6) days for the control group. One-third of patients did not achieve the threshold functional platelet count on the first day of admission, requiring more than one test. There was no difference in clinical outcomes between groups. Conclusions: A strategy individualised according to the platelet function test shortens the time to proximal femur fracture surgery under neuraxial anaesthesia in patients on chronic antiplatelet treatment. Better powered randomised clinical trials are needed to further evaluate the clinical impact and safety of this strategy.
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Rafael A, Mireia R, José María G, Victoria M, Angélica M, Noèlia V, Claudia Erica D, Rosa María A, Francesca R, Patricia G, Domingo B, José M, Angela MG, Maria Jose MZ. Evaluation of a strategy to shorten the time to surgery in patients on antiplatelet therapy with a proximal femur fracture (AFFEcT Study): Study protocol for a multicenter randomized controlled clinical trial. Medicine (Baltimore) 2019; 98:e15514. [PMID: 31083195 PMCID: PMC6531028 DOI: 10.1097/md.0000000000015514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/11/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Patients with femur fracture benefit from early surgery. Recent reports suggest that regional anesthesia may be superior to general anesthesia in these patients. Early surgery under spinal anesthesia could be performed safely by determining platelet function in patients receiving antiplatelet agents. METHODS Multicenter, randomized, open-label, parallel clinical trial expected to include 156 patients ≥ 18 years of age under chronic treatment with antiplatelet agents who develop a proximal femur fracture. EXCLUSION CRITERIA presence of multiple or pathological fractures, current treatment with vitamin K antagonists or new oral anticoagulants, and congenital or acquired coagulopathy.Patients will be randomized to eitherThe primary endpoint is time (hours) from admission to surgery. Secondary endpoints include: platelet function; postoperative bleeding; medical-surgical complications; perioperative and 1-year mortality; quality of life; length of hospital stay; cost-effectiveness; and cost-utility. Follow-up assessments will be performed during hospital admission and at 1, 6, and 12 months after surgery. POTENTIAL IMPACT OF THE STUDY The determination of platelet function at admission to the emergency department in patients with femoral fracture receiving antiplatelet therapy may permit earlier surgery under spinal anesthesia, thus shortening the hospital stay and reducing the risk of complications. These advantages associated with early surgery could positively impact patient well-being and also reduce treatment-related healthcare costs. ETHICS AND DISSEMINATION The study has been approved by the ethics committees at all participating centers. Their results will be disseminated in congresses and published in peer reviewed journals.
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Affiliation(s)
- Anaya Rafael
- Anesthesiology Service, Hospital de la Santa Creu i Sant Pau
| | | | - Gil José María
- Orthopedic Surgery and Tramatology Service, Hospital de la Santa Creu i Sant Pau
| | - Moral Victoria
- Anesthesiology Service, Hospital de la Santa Creu i Sant Pau
| | - Millan Angélica
- Orthopedic Surgery and Tramatology Service, Hospital de la Santa Creu i Sant Pau
| | - Vilalta Noèlia
- Hematology Service, Hospital de la Santa Creu i Sant Pau
| | - Delgado Claudia Erica
- Clinical Pharmacology Service, Fundació Institut de Recerca Hospital de la Santa Creu i Sant Pau
| | | | | | | | | | - Mateo José
- Hematology Service, Hospital de la Santa Creu i Sant Pau
| | - Merchán-Galvis Angela
- Public Health and Clinical Epidemiology Service-Iberoamerican Cochrane Centre, IIB Sant Pau, Spain
- Departamento de Medicina Social y Salud Familiar, Universidad del Cauca, Colombia
| | - Martinez-Zapata Maria Jose
- Public Health and Clinical Epidemiology Service-Iberoamerican Cochrane Centre, IIB Sant Pau, Spain
- CIBERESP, Spain
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