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Sorour O, Macki M, Tan L. Enhanced Recovery After Surgery Protocols and Spinal Deformity. Neurosurg Clin N Am 2023; 34:677-687. [PMID: 37718114 DOI: 10.1016/j.nec.2023.05.003] [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] [Indexed: 09/19/2023]
Abstract
The authors outline a review of preoperative, intraoperative, and postoperative considerations surrounding adult spinal deformity. Preoperative management topics include imaging, hemoglobin A1c levels before spine surgery, osteoporotic management, and prehabilitation. Topics surrounding intraoperative management include the use of antibiotics, liposomal bupivacaine, and Foley catheters. The authors also discuss postoperative questions surrounding analgesia, nausea and vomiting, thromboembolic prophylaxis, and early mobilization. Throughout their discussion, the authors incorporate enhanced recovery after surgery protocols to hopefully lead to future discussions regarding optimizing complex spinal patients.
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Affiliation(s)
- Omar Sorour
- Department of Neurosurgery, University of California, San Francisco, 505 Parnassus Avenue - Office M779, San Francisco, CA 94143, USA
| | - Mohamed Macki
- Department of Neurosurgery, University of California, San Francisco, 505 Parnassus Avenue - Office M779, San Francisco, CA 94143, USA
| | - Lee Tan
- Department of Neurosurgery, University of California, San Francisco, 505 Parnassus Avenue - Office M779, San Francisco, CA 94143, USA.
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Abstract
During sepsis, an initial prothrombotic shift takes place, in which coagulatory acute-phase proteins are increased, while anticoagulatory factors and platelet count decrease. Further on, the fibrinolytic system becomes impaired, which contributes to disease severity. At a later stage in sepsis, coagulation factors may become depleted, and sepsis patients may shift into a hypo-coagulable state with an increased bleeding risk. During the pro-coagulatory shift, critically ill patients have an increased thrombosis risk that ranges from developing micro-thromboses that impair organ function to life-threatening thromboembolic events. Here, thrombin plays a key role in coagulation as well as in inflammation. For thromboprophylaxis, low molecular weight heparins (LMWH) and unfractionated heparins (UFHs) are recommended. Nevertheless, there are conditions such as heparin resistance or heparin-induced thrombocytopenia (HIT), wherein heparin becomes ineffective or even puts the patient at an increased prothrombotic risk. In these cases, argatroban, a direct thrombin inhibitor (DTI), might be a potential alternative anticoagulatory strategy. Yet, caution is advised with regard to dosing of argatroban especially in sepsis. Therefore, the starting dose of argatroban is recommended to be low and should be titrated to the targeted anticoagulation level and be closely monitored in the further course of treatment. The authors of this review recommend using DTIs such as argatroban as an alternative anticoagulant in critically ill patients suffering from sepsis or COVID-19 with suspected or confirmed HIT, HIT-like conditions, impaired fibrinolysis, in patients on extracorporeal circuits and patients with heparin resistance, when closely monitored.
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Yang HQ, Liu MC, Yin WJ, Zhou LY, Zuo XC. Safety and Efficacy of Low Molecular Weight Heparin for Thromboprophylaxis in the Elderly: A Network Meta-Analysis of Randomized Clinical Trials. Front Pharmacol 2021; 12:783104. [PMID: 34955853 PMCID: PMC8703065 DOI: 10.3389/fphar.2021.783104] [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: 09/25/2021] [Accepted: 11/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Given their changing pathophysiology, elderly patients carry a high risk of embolism and bleeding events; hence, use of appropriate anticoagulants is very important. Low molecular weight heparin (LMWH) is one of the most widely used anticoagulants although LMWHs differ in their anti-Xa, antithrombin, and anticoagulant activities. To date, no study has directly compared the safety and efficacy of different LMWHs in the elderly. We aimed to compare such differences by conducting a network meta-analysis. Methods: We searched the Pubmed, Embase, and Cochrane databases for randomized controlled trials (RCTs) of LMWHs that included patients ≥60 years old up to July 22, 2020. Safety outcomes included venous thromboembolism (VTE) or VTE-related death, deep thrombus embolism, and pulmonary embolism. Safety outcomes were clinically relevant bleeding, major bleeding, minor bleeding, and all-cause death. We calculated relative ratios (RR) and 95% confidence intervals (CI) for all outcomes. The cumulative ranking probabilities (SUCRA) were conducted to rank the comparative effects and safety of all LMWHs. Results: We included 27 RCTs (30,441 elderly), comprising five LMWHs. LMWH was more effective than placebo in preventing VTE or VTE-related death (RR 0.36, 95% CI 0.25–0.53) but less effective than a novel oral anticoagulant (RR 1.59, 95% CI 1.33–1.91) and safer than acenocoumarol regarding risk of clinically relevant bleeding (RR 0.67, 95% CI 0.49–0.90). However, indirect comparison of efficacy and safety of the five LMWHs showed no significant difference in our network analysis, and the subgroup analyses (such as in patients with deep venous thrombosis, cardiac disease, or age >65 years old) supported the results. The SUCRA showed that tinzaparin performed best in preventing VTE or VTE-related death (SUCRA 68.8%, cumulative probability 42.3%) and all-cause death (SUCRA 84.2%, cumulative probability 40.7%), whereas nadroparin was predominant in decreasing the risk of clinically relevant bleeding (SUCRA 84.8%, cumulative probability 77.0%). Conclusions: On present evidence, there are no significant differences in the efficacy and safety of different LMWHs for the elderly. According to the rank probability analysis, nadroparin seems to be safer for the elderly with a high risk of bleeding, whereas tinzaparin is more effective for those with low bleeding risk.
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Affiliation(s)
- Hui-Qin Yang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Man-Cang Liu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Wen-Jun Yin
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Ling-Yun Zhou
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiao-Cong Zuo
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China.,Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
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Macki M, Haddad Y, Suryadevara R, Dabaja AL, Chedid M, Chang V. Prophylactic Low-Molecular-Weight Heparin Versus Unfractionated Heparin in Spine Surgery (PLUSS): A Pilot Matched Cohort Study. Neurosurgery 2021; 89:1097-1103. [PMID: 34634115 DOI: 10.1093/neuros/nyab363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/04/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite a proven superior efficacy of prophylactic low-molecular-weight heparin (LMWH) over unfractionated heparin (UFH) in the majority of surgical specialties, chemoprophylactic techniques after spine surgery have not been established because of the fear of epidural hematomas with LMWH. OBJECTIVE To determine the efficacy of LMWH vs UFH in the prevention of venous thromboembolism (VTE) events, balanced against the risk of epidural hematoma. METHODS This is the first matched cohort design that directly compares prophylactic LMWH to UFH after spine surgery for degenerative/deformity pathologies at a tertiary academic center. Prospectively collected patients receiving prophylactic LMWH and a historical cohort of patients receiving prophylactic UFH (prior to 2017) were matched in 1:1 ratio based on age ±5 yr, American Society of Anesthesiologists classification, location in the spinal column, and type of surgery. RESULTS Of 562 patients, VTE events equaled 1.4% (n = 8): 1.4% (n = 4) with LMWH was exactly equal to 1.4% (n = 4) with UFH. Epidural hematomas reached 0.8% (n = 5): 1.4% (n = 4) with UFH vs 0.3% (n = 1) with the LMWH (P = .178). Utilizing adjusted odds ratio (ORadj), the type of chemoprophylaxis after spine surgery failed to predict VTE events. Similarly, the chemoprophylactic technique failed to predict epidural hematoma in the multivariable regression analysis, although UFH trended toward a higher complication rate (ORadj = 3.15 [0.48-20.35], P = .227). CONCLUSION Chemoprophylactic patterns failed to predict VTE. Although no differences in epidural hematoma rates were detected, our analysis does highlight a trend toward a safer profile with LMWH vs UFH. LMWH may be a safe alternative to UFH in spine surgery.
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Affiliation(s)
- Mohamed Macki
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Yazeed Haddad
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | | | - Abed Latif Dabaja
- Department of Internal Medicine, Garden City Hospital, Garden City, Michigan, USA
| | - Mokbel Chedid
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Victor Chang
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
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Macki M, Chang V. Commentary: Comparison of the Safety of Prophylactic Anticoagulants After Intracranial Surgery. Neurosurgery 2021; 89:E158-E159. [PMID: 34161590 DOI: 10.1093/neuros/nyab230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 05/16/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mohamed Macki
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Victor Chang
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
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Bell JS, Florence TJ, Phillips HW, Patel K, Macaluso NJ, Villanueva PG, Naik PK, Kim W. Comparison of the Safety of Prophylactic Anticoagulants After Intracranial Surgery. Neurosurgery 2021; 89:527-536. [PMID: 34161594 DOI: 10.1093/neuros/nyab221] [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: 10/27/2020] [Accepted: 04/29/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) represents a rare but preventable postoperative complication. Unfractionated heparin (UH) and low-molecular-weight heparin (LMWH) are used to prevent VTE, but comparative studies of their safety and efficacy in the neurosurgical context are limited. OBJECTIVE To determine the relative safety and efficacy of UH and LMWH for prophylaxis after cranial surgery. METHODS We performed a retrospective analysis of 3204 elective intracranial surgical admissions in 2901 patients over the period 2013 to 2018. From chart review, we extracted demographic and clinical features, including diagnosis and procedure, drugs administered, and the occurrence of VTE events. To compare postoperative outcomes, we performed propensity score matching of patients receiving different drugs, and reviewed postoperative cranial imaging. To contextualize our results, we selected 14 prior neurosurgical studies of VTE prophylaxis to compare our outcomes to the existing literature. RESULTS In our sample of 3204 admissions, the overall rate of VTE was 0.8% (n = 27). Rates of VTE were not statistically different in matched cohorts receiving UH and LMWH (1.7% vs 1.0%, respectively); however, LMWH was associated with a higher rate of clinically significant intracranial hemorrhage (ICH) (3.4% vs 0.5%, P = .008). Literature review and meta-analysis supported these findings. Across studies, UH and LMWH were associated with similar rates of VTE. Studies in which patients received LMWH reported significantly higher rates of ICH (4.9% higher, P = .005). CONCLUSION We find that LMWH and UH show similar efficacy in preventing VTE; however, LMWH is associated with higher rates of ICH.
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Affiliation(s)
- Joseph S Bell
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - T J Florence
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - H Westley Phillips
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Kunal Patel
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Nicholas J Macaluso
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Paulina G Villanueva
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Priyanka K Naik
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Won Kim
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
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Zervos TM, Bazydlo M, Tundo K, Macki M, Rock J. Risk Factors Associated with Symptomatic Deep Vein Thrombosis Following Elective Spine Surgery: A Case-Control Study. World Neurosurg 2020; 144:e460-e465. [PMID: 32889183 DOI: 10.1016/j.wneu.2020.08.182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Few studies provide insight into risk factors (RFs) associated with postoperative deep vein thrombosis (DVT) following elective spinal surgery. DVTs are detrimental in this population because of the risk of pulmonary embolization or surgical site hemorrhage with treatment. OBJECTIVE Elective spine surgery patients have a low incidence of DVT, thus a case-control study was selected to investigate RFs associated with postoperative, symptomatic DVT. METHODS Cases were matched to controls in a 1:2 ratio based on surgery type. Risk of having a prior DVT and choice of subcutaneous heparin dosing following surgery was analyzed in a multivariate regression model with other potentially confounding variables. RESULTS A total of 195 patients were included in this study. Independent of patient age, history of DVT was associated with postoperative symptomatic DVT (odds ratio [OR], 4.09; 95% confidence interval [CI], 1.22-13.78). Two versus 3 times daily postoperative heparin dosing (OR, 1.56; 95% CI, 0.32-7.56), surgery length (OR, 1.32; 95% CI, 0.98-1.79), and patient age (OR, 1.04; 95% CI, 1.0-1.08) were not statistically significant, independent RFs. Older age and longer length of surgery trended toward association with DVT without reaching significance. Length of stay was increased from 3-5 days (P < 0.001) in DVT patients compared with controls. CONCLUSIONS These results suggest that patients with a history of DVT undergoing elective spinal surgery are at higher risk of developing symptomatic DVT postoperatively resulting in significantly increased length of stay. Further studies on additional preoperative screening and medical optimization in elective spine surgery patients may help reduce the rate of symptomatic, postoperative DVT.
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Affiliation(s)
- Thomas M Zervos
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA.
| | - Michael Bazydlo
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, Michigan, USA
| | - Kelly Tundo
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Mohamed Macki
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jack Rock
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
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