Antiplatelet agents in the perioperative period: expert recommendations of the French Society of Anesthesiology and Intensive Care (SFAR) 2001--summary statement (original) (raw)
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Comparison of Two Strategies for the Management of Antiplatelet Therapy During Urgent Surgery
Annals of Thoracic Surgery, 2005
The optimal management of aspirin and clopidogrel therapy before surgery in patients with acute coronary syndrome is uncertain. Aspirin and clopidogrel within 5 days of surgery increases postoperative bleeding and reexploration. However, in acute coronary syndrome patients the risk of bleeding must be balanced against the risks of discontinuing the treatment and delaying surgery.From June 2002 to July 2003, patients undergoing urgent coronary artery bypass graft surgery (CABG) for acute coronary syndrome were randomly assigned to one of two groups. The treatment group remained on aspirin and clopidogrel therapy till surgery, receiving intraoperative aprotinin. The placebo group received placebo for 5 days before surgery and received placebo infusions intraoperatively. Platelet reactivity in response to adenosine diphosphate was assessed by whole blood single-platelet counting. Of the 88 patients eligible, 50 entered the study.Postoperative blood loss was significantly greater in the placebo group than in the treatment group (702 ± 120 mL versus 446 ± 62 mL, p = 0.004). This difference was observed as early as 8 hours postoperatively (385 ± 66 mL versus 266 ± 36 mL, p = 0.03). Patients in the placebo group also required more blood transfusions (1 ± 0.3 units versus 0.3 ± 0.2 units, p = 0.03). Three patients in each group underwent surgical reexploration for bleeding.The strategy of continuing aspirin and clopidogrel therapy with intraoperative aprotinin reduces postoperative blood loss, transfusion requirements, prevents delay to surgical treatment, and may prevent major adverse cardiac events before surgery.
Antiplatelet agents in perioperative noncardiac surgeries: to maintain or to suspend?
Therapeutics and clinical risk management, 2018
When prescribing antiplatelet agents, physicians face the challenge of protecting patients from thromboembolic events without inducing bleeding damage. However, especially in the perioperative period, the use of these medications requires a carefully balanced assessment of their risks and benefits. To conduct a systematic review to check whether the antiplatelet agent is to be maintained or suspended in the perioperative period of noncardiac surgeries. A comprehensive literature search using Science Direct, Scopus, MEDLINE-PubMed, and Web of Science was undertaken. Clinical trials of noncardiac surgeries with patients taking regular anti-platelet therapy, published between 2013 and 2018. A total of 1,302 studies were initially identified, with only four meeting the inclusion criteria. The selected studies were conducted in different countries such as, including India (2), Serbia (1), and the USA (1). The age group was similar in all studies, from 61 to 75 years. The most frequent su...
Management of surgical patients receiving anticoagulation and antiplatelet agents
British Journal of Surgery, 2008
Background: Temporary interruption of long-term anticoagulation and antiplatelet therapy during surgical procedures exposes patients to thrombotic risk. Continuation of these agents, however, is associated with an increased risk of bleeding. Managing anticoagulation can be a particular challenge in the emergency setting.
British Journal of Anaesthesia, 2016
Background. The bleeding impact of dual antiplatelet therapy (DAPT), aspirin and clopidogrel, maintained until coronary artery bypass graft surgery (CABG), is still a matter of debate. The lack of preoperative antiplatelet activity measurement and heterogeneity of antifibrinolytic protocols in prior studies make the conclusions questionable. The aim of this prospective study was to determine, after preoperative antiplatelet activity measurement, if the maintenance of DAPT until CABG increases bleeding in patients treated with tranexamic acid (TA). Methods. This observational study included 150 consecutive patients, 89 treated with aspirin and 61 treated with DAPT, undergoing a first-time planned on-pump CABG with TA treatment. Antiplatelet activity was measured with platelet aggregation tests and quantification of VASP phosphorylation. Postoperative bleeding at 24 h was recorded and propensity score analysis was performed. Results. Based on VASP assay, 54% of patients showed high on-clopidogrel platelet activity inhibition. Postoperative bleeding at 24 h increased by 22% in the DAPT group, compared with the aspirin group (680 [95% CI: 360-1670] vs 558 [95%CI: 267-1270] ml, P < 0.01), consistent with increased blood transfusion (21% vs 7%, P ¼ 0.01); a higher incidence of mediastinitis did not reach statistical significance (15% vs 4%, P ¼ 0.05). Bleeding correlated with the extent of clopidogrel antiplatelet effect, with the best correlation for the VASP assay. Conclusions. Maintenance of DAPT until the day of CABG in patients treated with TA, increased postoperative bleeding at 24 h in parallel with preoperative antiplatelet activity induced by clopidogrel.
Guideline on antiplatelet and anticoagulation management in cardiac surgery
European Journal of Cardio-Thoracic Surgery, 2008
This document presents a professional view of evidence-based recommendations around the issues of antiplatelet and anticoagulation management in cardiac surgery. It was prepared by the Audit and Guidelines Committee of the European Association for Cardio-Thoracic Surgery (EACTS). We review the following topics: evidence for aspirin, clopidogrel and warfarin cessation prior to cardiac surgery; perioperative interventions to reduce bleeding including the use of aprotinin and tranexamic acid; the use of thromboelastography to guide blood product usage; protamine reversal of heparin; the use of factor Vlla to control severe bleeding; anticoagulation after mechanical, tissue valve replacement and mitral valve repair; the use of antiplatelets and clopidogrel after cardiac surgery to improve graft patency and reduce thromboembolic complications and thromboprophylaxis in the postoperative period. This guideline is subject to continuous informal review, and when new evidence becomes available. The formal review date will be at 5 years from publication (September 2013).
Clopidogrel and Bleeding after General Surgery Procedures
American Surgeon, 2008
Although many studies in the cardiothoracic literature exist about the relationship between clopidogrel and postoperative bleeding, there is scarce data in the general surgery literature. We assessed whether there are increased bleeding complications, morbidity, mortality, and resource utilization in patients who are on clopidogrel (Plavix ®) within 1 week before undergoing a general surgery procedure. Fifty consecutive patient charts were retrospectively reviewed after identifying patients who had pharmacy orders for clopidogrel and who underwent a general surgery procedure between 2003 and 2007. Patients who took clopidogrel within 6 days before surgery (group I, n = 28) were compared with patients who stopped clopidogrel for 7 days or more (group II, n = 22). A larger percentage of patients who took their last dose of clopidogrel within 1 week of surgery (21.4% vs 9.5%) had significant bleeding after surgery requiring blood transfusion. However, there were no significant differences between the groups in operative or postoperative blood transfusions (P = 0.12, 0.53), decreases in hematocrit (P = 0.21), hospital stay (P = 0.09), intensive care unit stay (P = 0.41), late complications (P = 0.45), or mortality (P = 0.42). Although our cohort is limited in size, these results suggest that in the case of a nonelective general surgery procedure where outcomes depend on timely surgery, clopidogrel taken within 6 days before surgery should not be a reason to delay surgery. However, careful attention must be paid to meticulous hemostasis, and platelets must be readily available for transfusion in the operating room.