The effect of low-dose tranexamic acid on postoperative blood loss in patients treated with clopidogrel and aspirin (original) (raw)
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Clopidogrel does not increase bleeding and allogenic blood transfusion in coronary artery surgery
European Journal of Cardio-Thoracic Surgery, 2004
Objectives: Platelet dysfunction is one of the major reasons of postoperative bleeding following coronary artery surgery. The aim of this study was to evaluate the effects of clopidogrel; a specific and potent irreversible inhibitor of platelet aggregation; on bleeding and use of blood and blood products after coronary artery bypass surgery (CABG). Methods: Preoperative patient characteristics and perioperative and postoperative data were collected prospectively in 1628 consecutive patients undergoing isolated CABG performed by the same surgical and anesthesia team. Of these, 48 were receiving clopidogrel preoperatively. Of the 1628 patients, 1456 underwent elective and 172 (10.6%) underwent non-elective operation. Thirty-six (2.5%) of the elective patients and 12 (7%) of the non-elective patients were using clopidogrel, preoperatively. Baseline characteristics, chest tube output, and the need for reexploration or for blood and blood product transfusion of clopidogrel recipients and non-recipients were compared. The clopidogrel group had higher prothrombin time level (12.6^1.6; 11.5^1.7 s, P ¼ 0:013), however comparable aPTT level (32.6^4.5 vs. 31.4^4.5 s), and platelet count (275 000^98 000 vs. 280 000^72 000 dl 21). Results: The need for reexploration or for blood and blood product transfusion, chest tube output, ICU length of stay (20.1^2.9 vs. 21.9^13.5 h; P ¼ NS), and hospital length of stay (5.5^1.7 vs. 5.4^2.1 days; P ¼ NS) were similar in clopidogrel recipients and non-recipients, respectively. Further analysis demonstrated no significant difference in use of homologous blood or fresh frozen plasma, amount of postoperative bleeding and reoperation rates for bleeding as well as length of intensive care unit and hospital stay between the clopidogrel and the control groups both in elective and non-elective patients. Conclusions: The results of this study suggest that preoperative use of clopidogrel is not associated with increased bleeding and need for surgical exploration as well as risk of blood and blood product transfusion after CABG.
Circulation, 2006
Premedication with clopidogrel has reduced thrombotic complications after percutaneous coronary revascularization procedures. However, because of the enhanced and irreversible platelet inhibition by clopidogrel, patients requiring surgical revascularization have a higher risk of bleeding complications and transfusion requirements. A principal benefit of surgical coronary revascularization without cardiopulmonary bypass is its lower hemorrhagic sequelae. The purpose of this study was to evaluate the effect of preoperative clopidogrel administration in the incidence of hemostatic reexploration, blood product transfusion rates, morbidity, and mortality in patients undergoing off-pump coronary artery bypass graft surgery using a large patient sample and a risk-adjusted approach. Two hundred eighty-one patients (17.9%) did and 1291 (82.1%) did not receive clopidogrel before their surgery, for a total of 1572 patients undergoing isolated off-pump coronary artery bypass graft surgery between January 2000 and June 2002. Risk-adjusted logistic regression analyses and a matched pair analyses by propensity scores were used to assess the association between clopidogrel administration and reoperation as a result of bleeding, intraoperative and postoperative blood transfusions received, and the need for multiple transfusions. Hemorrhage-related preoperative risk factors identified in the literature and those found significant in a univariate model were used. The clopidogrel group had a higher likelihood of hemostatic reoperations (odds ratio [OR], 5.1; 95% confidence interval [CI], 2.47 to 10.47; P<0.01) and an increased need in overall packed red blood cell (OR, 2.6; 95% CI, 1.94 to 3.60; P<0.01), multiple unit (OR, 1.6; 95% CI, 1.07 to 2.48; P=0.02), and platelet (OR, 2.5; 95% CI, 1.77 to 3.66; P<0.01) transfusions. Surgical outcomes and operative mortality (1.4% versus 1.4%; P=1.00) were not statistically different. Clopidogrel administration in the cardiology suite increases the risk for hemostatic reoperation and the requirements for blood product transfusions during and after off-pump coronary artery bypass graft surgery.
Clopidogrel and Bleeding after General Surgery Procedures
The 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 differenc...
European Heart Journal, 2004
Thrombotic complications after percutaneous coronary intervention procedures have decreased in past years mainly due to the use of clopidogrel antiplatelet therapy. However, the risk of bleeding due to enhanced and irreversible platelet inhibition in patients who will require surgical coronary revascularization instead has not been adequately addressed in the literature. The purpose of this study was to evaluate the effect of pre-operative clopidrogel exposure in haemorrhage-related re-exploration rates, peri-operative transfusion requirements, morbidity, and mortality in patients undergoing coronary artery bypass grafting (CABG) surgery. A study population of 2359 patients undergoing isolated CABG between January 2000 and June 2002 was reviewed. Of these, 415 (17.6%) received clopidogrel prior to CABG surgery, and 1944 (82.4%) did not. A risk-adjusted logistic regression analysis was used to assess the association between clopidogrel pre-medication (vs. no) and haemostatic re-operation, intraoperative and post-operative blood transfusion rates, and multiple transfusions received. Haemorrhage-related pre-operative risk factors identified from the literature and those found significant in a univariate model were used. Furthermore, a sub-cohort, matched-pair by propensity scores analysis, was also conducted. The clopidogrel group had a higher likelihood of haemostatic re-operation [OR = 4.9, (95% CI, 2.63-8.97), P < 0.01], an increase in total packed red blood cell transfusions [OR = 2.2, (95% CI, 1.70-2.84), P < 0.01], multiple unit blood transfusions [OR = 1.9, (95% CI, 1.33-2.75), P < 0.01] and platelet transfusions [OR = 2.6, (95% CI, 1.95-3.56), P < 0.01]. Surgical outcomes and operative mortality [OR = 1.5, (95% CI, 0.36-6.51), P = 0.56] were not significantly different. Pre-operative clopidogrel exposure increases the risk of haemostatic re-operation and the requirements for blood and blood product transfusion during, and after, CABG surgery.
Does Clopidogrel Increase Blood Loss Following Coronary Artery Bypass Surgery?
The Annals of Thoracic Surgery, 2004
Background. Clopidogrel (Plavix) is a potent inhibitor of platelet aggregation used concomitantly with percutaneous coronary interventions and in patients with acute coronary syndromes. Its favorable effects on preventing thrombus formation may have deleterious effects on hemostasis in patients undergoing coronary surgery. Methods. Data were collected prospectively on 312 consecutive urgent or emergent coronary artery bypass patients from July 1999 through April 2001 at a tertiary care center. Patients were stratified into three groups: clopidogrel within 4 days of operation (n ؍ 41), clopidogrel continued until 5 to 8 days before operation (n ؍ 39), and clopidogrel discontinued more than 8 days before operation or were never taking clopidogrel (n ؍ 232). Results. Preoperative and intraoperative characteristics were similar among all groups. Mediastinal and pericardial chest tube losses in the first 24 hours were 1,044 ؎ 750 mL in the clopidogrel within 4 days group, 528 ؎ 250 mL in the clopidogrel 5 to 8 days group, and 573 ؎ 329 mL in the clopidogrel more than 8 days group (p < 0.01). The mean total blood product transfusions were 12.2 ؎ 15.4 U, 1.2 ؎ 2.0 U, and 2.6 ؎ 5.7 U, respectively (p < 0.001). Reoperation for bleeding was noted in 14.6%, 2.6%, and 1.7%, respectively (p ؍ 0.002). The median hospital lengths of stay for the three groups were 9 days, 7 days, and 7 days, respectively (p ؍ 0.018). There were no statistically significant differences in mortality rate, myocardial infarction, stroke, mediastinitis, or postoperative renal failure among the groups. Multivariable analysis revealed that clopidogrel within 0 to 4 days of operation was an independent predictor of transfusion requirements (OR 4.22, 95% confidence interval [CI] 2.07, 9.34, p ؍ 0.001), intensive care unit (ICU) length of stay (OR 3.14, 95% CI 1.40, 7.04, p ؍ 0.006), and total hospital length of stay (coefficient 7.65, se 2.41, p ؍ 0.002). Conclusions. Clopidogrel within 4 days of coronary bypass surgery is associated with increased blood losses and reoperation for bleeding and, according to multivariable models, is an independent risk factor for increased transfusion requirements and prolonged ICU and hospital length of stay.
Asian Journal of Medical Sciences, 2020
Tranexamic acid is widely used as an antifibrinolytic drug to reduce blood loss intraoperative and postoperative time periods as well as to reduce transfusion of allogeneic blood. After releasing in the market, multidisciplinary surgeries have wide use of tranexamic acid due to its antifibrinolytic effect to reduce bleeding and transfusion of blood. In literature, there were mentioned a few adverse effects like thromboembolism, seizure, anaphylactic reaction, etc which are still unsolved questions to date. The aim of this review to minimize the blood loss from acute bleeding in different situations by updating the doses used in a different clinical scenario,since the release of tranexamic acid. It also gives an idea about appropriate doses to reduce blood loss, need for blood transfusion, minimize adverse effects and to understand the wide scope of application of TXA to date.
Tranexamic acid in emergency coronary surgery. Time for routine use
2012
Address for correspondence: dr n. med. Andrzej Biskupski, Klinika Kardiochirurgii Pomorskiego Uniwersytetu Medycznego, ul. Powstańców Wielkopolskich 72, 71-110 Szczecin, tel. +48 91 466 13 91, faks +48 91 466 13 93, e-mail: a.biskupski@vp.pl Abstract Aim of the study: To evaluate retrospectively the blood sparing effect and the side effects of prophylactic treatment with tranexamic acid in patients on antiplatelet medication (aspirin and clopidogrel) requiring emergency coronary surgery. Material and methods: Perioperative data on 120 patients consecutively operated on in our department from July 2009 until June 2010 for coronary artery disease on an emergency basis were analysed retrospectively. During the first 6 months 60 patients were operated on and received no antifibrinolytic treatment (control group). The next 60 patients (TA group) received tranexamic acid according to a new protocol implemented in January 2010. Mortality and morbidity including postoperative bleeding and b...
European Heart Journal, 2007
Aims Aspirin combined with clopidogrel is the treatment of choice for acute coronary syndromes. Although the maintenance of aspirin until surgery does not affect postoperative bleeding after coronary artery bypass graft (CABG) surgery, the latter may be dramatically increased when clopidogrel is continued over a period of 5 days preoperatively. Methods and results This prospective observational study included 217 consecutive patients scheduled for first-time CABG. Postoperative bleeding and blood transfusion requirements were compared (equivalence) between patients pretreated during a period of 5 days prior surgery by either aspirin alone (n ¼ 157) or combined with clopidogrel (n ¼ 60). Aprotinin was systematically used in all these patients considered as high risk for bleeding. We found no significant difference between both groups concerning the preoperative characteristics except for unstable angina (33 vs. 19%, P ¼ 0.02) and left main coronary artery stenosis (27 vs. 13%, P ¼ 0.02), which were more frequent in patients receiving clopidogrel. The median chest tube output was similar in both groups 24 h postoperatively at 350 mL (95% CI 150-850) vs. 375 mL (95% CI 175-875), and the difference between groups (7%, 95% CI 29 to 22) did not encompass the predetermined margins of equivalence (25%). No significant difference was found on blood transfusion use (38 vs. 38%, P ¼ 0.99). After adjustment by a propensity score, we found that clopidogrel was not associated with an increased risk of excessive bleeding. Conclusion In patients undergoing first-time CABG and treated prophylactically with aprotinin, aspirin and clopidogrel may be continued until surgery without increasing postoperative bleeding or transfusion requirements.
Circulation, 2006
We read with great interest the study by Kapetanakis et al, 1 which confirmed that clopidogrel administration increased the risk for hemostatic reexploration and also increased transfusion rates during and after off-pump coronary surgery. They and several other groups have previously reported similar results in patients on clopidogrel undergoing on-pump coronary surgery. The present recommendation in the accompanying editorial 2 is in line with the American College of Cardiology/ American Heart Association 2004 guideline update for coronary artery bypass graft surgery 3. "If clinical circumstances permit, clopidogrel should be withheld for 5 days before performance of [coronary artery bypass graft] surgery" (p e394). In an earlier study by Kapetanakis et al (as well as in their present study 1), approximately 18% of the patients undergoing coronary surgery were treated with clopidogrel. Further, recent data indicate that up to 5% of all patients presenting for coronary surgery 4 may require urgent or immediate coronary artery bypass grafting after clopidogrel administration, and delaying surgery for the return of platelet function may not even be an option. Intraoperative administration of aprotinin in patients on clopidogrel undergoing coronary surgery reduces bleeding and the number of transfusions, however, as we have demonstrated in a randomized controlled clinical trial. 5 Thus, we agree that patients on clopidogrel who are scheduled for coronary surgery should have their operation postponed for a minimum of 5 days if possible. However, fairly often, surgery cannot be delayed; in these cases, intraoperative aprotinin will reduce blood loss and transfusion requirements after coronary surgery. Disclosures Dr van der Linden has received an unrestricted research grant from Bayer Sweden. The other authors report no conflicts.