Preoperative platelet transfusions to reverse antiplatelet therapy for urgent non-cardiac surgery: an observational cohort study

Aspirin use and bleeding events during thrombocytopenia after autologous stem-cell transplantation for multiple myeloma

Background

In patients with cardiovascular (CV) comorbidities that necessitate antiplatelet therapy (APT), its optimal management during chemotherapy-induced thrombocytopenia remains elusive, as the risk of bleeding has to be balanced against the risk of CV events. The purpose of this study was to assess the risk for bleeding with APT during thrombocytopenia in patients with multiple myeloma undergoing high-dose chemotherapy and subsequent autologous stem-cell transplantation (ASCT) with and without acetylsalicylic acid (ASA) as comedication.

Methods

We assessed patients who underwent ASCT at the Heidelberg University Hospital between 2011 and 2020 for bleeding events, management strategies for ASA intake during thrombocytopenia, transfusion requirements, and the occurrence of CV events.

Results

There were 57/1,113 patients who continued ASA until at least 1 day after ASCT; thus, a continuous platelet inhibition during thrombocytopenia was assumed. Most of the patients (41/57) continued ASA until they had a platelet count of 20-50/nl. This range reflects the kinetics of thrombocytopenia and nondaily measurements of platelets during ASCT. A tendency toward a higher risk for bleeding events in the ASA group was demonstrated (1.9% (control group) vs. 5.3% (ASA), p = 0.082). The risk factors for bleeding in multivariate analysis were the duration of thrombocytopenia < 50/nl, a history of gastrointestinal bleeding, and diarrhea. The factors predicting the duration of thrombocytopenia were age >60 years, a hematopoietic stem-cell transplantation comorbidity index ≥3, and an impaired bone marrow reserve at admission. CV events occurred in three patients; none of them took ASA or had an indication for APT.

Conclusions

The intake of ASA until thrombocytopenia with a platelet count of 20-50/nl appears safe, although an elevated risk cannot be excluded. If ASA is indicated for the secondary prevention of CV events, the evaluation of risk factors for bleeding and a prolonged time of thrombocytopenia before conditioning is crucial to adapt the strategy for ASA intake during thrombocytopenia.

Is Continuing Anticoagulation or Antiplatelet Therapy Safe Prior to Kidney Transplantation?

Background

Patients undergoing kidney transplantation are often placed on anticoagulation or antiplatelet therapy, and their perioperative management is often challenging. This study aimed to determine the safety of continuing anticoagulation or antiplatelet therapy prior to kidney transplantation. The primary outcome was bleeding after transplantation.

Material/Methods

Patients who underwent kidney transplantation between January 2017 and July 2019 were included and divided into 3 groups: pretransplant anticoagulation with warfarin (WARF; n=23); pretransplant antiplatelet therapy with clopidogrel/aspirin (ASA/CLOP; n=32); and control (CTL; n=197). Patients received kidneys from live or deceased donors. Preoperative INRs and platelet counts were compared to ensure therapeutic anticoagulation in the warfarin group and no significant platelet count variation among groups. The primary outcome was graft exploration for bleeding at 3 and 6 months after transplantation. Secondary outcomes included perioperative transfusion requirements, prolonged length of stay (>7 days), and outcomes at 3 and 6 months after transplantation, including hemodialysis and rejection rates and creatinine levels.

Results

Pretransplant INR was significantly greater in the warfarin group (CTL 1.1, WARF 2.2, ASA/CLOP 1.2; P<0.01). There were no differences in pretransplant platelet count (CTL 202×10³, WARF 186×10³, ASA/CLOP 194×10³; P=0.31), graft exploration for bleeding at 3 (CTL 3%, WARF 0%, ASA/CLOP 3%; P=0.69) and 6 months after transplantation (CTL 1%, WARF 4%, ASA/CLOP 0%; P=0.12), or perioperative blood transfusion requirements (CTL 4%, WARF 4%, ASA/CLOP 14%; P=0.13). Prolonged length of stay was similar (CTL 24%, WARF 26%, ASA/CLOP 44%; P=0.08). There were no significant differences among groups at 3 months in dialysis (CTL 2%, WARF 0%, ASA/CLOP 0%; P=0.71), creatinine (CTL 1.5 mg/dL, WARF 1.7 mg/dL, ASA/CLOP 1.7; P=0.13), or rejection (CTL 6%, WARF 0%, ASA/CLOP 0%) or at 6 months in dialysis (CTL 3%, WARF 0%, ASA/CLOP 0%; P=0.49), creatinine (CTL 1.5 mg/dL, WARF 1.7 mg/dL, ASA/CLOP 1.5; P=0.49), or rejection (CTL 1%, WARF 0%, ASA/CLOP 3%).

Conclusions

Continuing anticoagulation or antiplatelet was safe in not increasing bleeding complications or perioperative transfusion requirements. Outcomes were similar at 3 and 6 months among groups. This strategy avoids exposing patients to risk of thrombosis if treatment is held and simplifies proceeding to transplantation.

Acute myocardial infarction and arterial embolism in a patient with newly diagnosed renal mass: management dilemmas! A case report

Background

Cancer is often associated with a hypercoagulable state and new thrombosis is often the first clinical manifestation of cancer. Surgical treatment of the primary tumor is crucial since it provides the only curative approach in most cases, but management of patients is highly complex, especially in the presence of new antiplatelet drugs and/or anticoagulants. Paraneoplastic syndromes (PNS) represent a frequent complication of renal cell carcinomas (RCC) and include different hematological symptoms in patients, whilst occlusion of arterial blood vessels displays a rare form of PNS accompanying renal tumors.

Case presentation

We report the case of a 62-year old man who was initially hospitalized due to acute coronary syndrome. He subsequently underwent coronary angioplasty treatment including multiple stenting and treatment with ticagrelor and aspirin. Post-interventional, acute arterial thrombotic emboli of several limb arteries required thrombectomy. By computer tomography we identified a renal lesion suspicious for an RCC and suspected a PNS as underlying cause of the thrombotic complications. Triple anticoagulant therapy was maintained with therapeutic dose low molecular weight heparin (LMWH), aspirin, and clopidogrel, by which we replaced ticagrelor. Surgery was postponed for 4 weeks. We paused LMWH, aspirin and clopidogrel only at the day of surgery and perioperatively restored hemostasis by transfusion of two platelet concentrates. Laparoscopic nephrectomy was uneventful. Pathology confirmed a clear cell RCC. The patient fully recovered whilst slowly reducing anticoagulation dose.

Conclusions

A multidisciplinary team approach of experts in urology, cardiology and hemostasis was key in managing this patient since a personalized thrombosis consult was needed to minimize the risk of reinfarction due to in-stent thrombosis. We report a therapeutic protocol that may be helpful for the management of similar cases. Furthermore, the finding of thrombotic arterial occlusions in larger blood vessels represents a novel complication of PNS in RCC and adds to the varied possible manifestations of this clinical chameleon.

Perioperative management of antiplatelet therapy in noncardiac surgery

PURPOSE OF REVIEW

Perioperative management of antiplatelet agents (APAs) in the setting of noncardiac surgery is a controversial topic of balancing bleeding versus thrombotic risks.

RECENT FINDINGS

Recent data do not support a clear association between continuation or discontinuation of APAs and rates of ischemic events, bleeding complications, and mortality up to 6 months after surgery. Clinical factors, such as indication and urgency of the operation, time since stent placement, invasiveness of the procedure, preoperative cardiac optimization, underlying functional status, as well as perioperative control of supply-demand mismatch and bleeding may be more responsible for adverse outcome than antiplatelet management.

SUMMARY

Perioperative management of antiplatelet therapy (APT) should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic/thrombotic and bleeding risks. Where possible, surgery should be delayed for a minimum of 1 month but ideally for 3-6 months from the index cardiac event. If bleeding risk is acceptable, dual APT (DAPT) should be continued perioperatively; otherwise P2Y12 inhibitor therapy should be discontinued for the minimum amount of time possible and aspirin monotherapy continued. If bleeding risk is prohibitive, both aspirin and P2Y12 inhibitor therapy should be interrupted and bridging therapy may be considered in patients with high thrombotic risk.

Impaired hemostatic activity of healthy transfused platelets in inherited and acquired platelet disorders: Mechanisms and implications

Platelet transfusions can fail to prevent bleeding in patients with inherited platelet function disorders (IPDs), such as Glanzmann's thrombasthenia (GT; integrin αIIbβ3 dysfunction), Bernard-Soulier syndrome [BSS; glycoprotein (GP) Ib/V/IX dysfunction], and the more recently identified nonsyndromic RASGRP2 variants. Here, we used IPD mouse models and real-time imaging of hemostatic plug formation to investigate whether dysfunctional platelets impair the hemostatic function of healthy donor [wild-type (WT)] platelets. In Rasgrp2-/- mice or mice with platelet-specific deficiency in the integrin adaptor protein TALIN1 ("GT-like"), WT platelet transfusion was ineffective unless the ratio between mutant and WT platelets was ~2:1. In contrast, thrombocytopenic mice or mice lacking the extracellular domain of GPIbα ("BSS-like") required very few transfused WT platelets to normalize hemostasis. Both Rasgrp2-/- and GT-like, but not BSS-like, platelets effectively localized to the injury site. Mechanistic studies identified at least two mechanisms of interference by dysfunctional platelets in IPDs: (i) delayed adhesion of WT donor platelets due to reduced access to GPIbα ligands exposed at sites of vascular injury and (ii) impaired consolidation of the hemostatic plug. We also investigated the hemostatic activity of transfused platelets in the setting of dual antiplatelet therapy (DAPT), an acquired platelet function disorder (APD). "DAPT" platelets did not prolong the time to initial hemostasis, but plugs were unstable and frequent rebleeding was observed. Thus, we propose that the endogenous platelet count and the ratio of transfused versus endogenous platelets should be considered when treating select IPD and APD patients with platelet transfusions.

Acquired platelet function disorders

The possibility of an acquired platelet function disorder should be considered in patients who present with recent onset muco-cutaneous bleeding. Despite the availability of newer and faster platelet function assays, light transmission aggregometry (LTA) remains the preferred diagnostic test. This review examines and discusses the causes of acquired platelet dysfunction; most commonly drugs, dietary factors, medical disorders and procedures. In addition to well-known antiplatelet therapies, clinicians should be alert for newer drugs which can affect platelets, such as ibrutinib. There is little clinical trial evidence to guide the management of acquired platelet function defects, but we summarise commonly employed strategies, which include addressing the underlying cause, antifibrinolytic agents, desmopressin infusions, and in selected patients, platelet transfusions.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

Background

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

Methods

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

Results

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

Conclusions

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.