Perioperative Management Of Anticoagulation Research Articles

Perioperative Management of Vitamin K Antagonists and Direct Oral Anticoagulants: A Systematic Review and Meta-analysis

The management of patients who are receiving chronic oral anticoagulation therapy and require an elective surgery or an invasive procedure is a common clinical scenario. What is the best available evidence to support the development of American College of Chest Physicians guidelines on the perioperative management of patients who are receiving long-term vitamin K agonist (VKA) or direct oral anticoagulant (DOAC) and require elective surgery or procedures? A literature search including multiple databases from database inception through July 16, 2020, was performed. Meta-analyses were conducted when appropriate. In patients receiving VKA (warfarin) undergoing elective noncardiac surgery, shorter (< 5days) VKA interruption is associated with an increased risk of major bleeding. In patients who required VKA interruption, heparin bridging (mostly with low-molecular-weight heparin [LMWH]) was associated with a statistically significant increased risk of major bleed (relative risk [RR], 9.1; 95%CI, 1.62-51.3), representing a very low certainty of evidence (COE). Compared with DOAC interruption 1 to 4days before surgery, continuing DOACs was not associated with a statistically significant difference in the risk of bleeding, representing a very low COE. Continuing dabigatran was associated with a statistically significant increased risk of thromboembolism (RR, 2.2; 95%CI, 1.3-3.8), representing a low COE. In patients who needed DOAC interruption, bridging with LMWH was associated a with statistically significant increased risk of minor bleeding compared with no bridging (RR, 1.7; 95%CI, 1.13-2.7), representing a low COE. The certainty in the evidence supporting the perioperative management of anticoagulants remains limited. No high-quality evidence exists to support the practice of heparin bridging during the interruption of VKA or DOAC therapy for an elective surgery or procedure or for the practice of interrupting VKA therapy for minor procedures, including cardiac device implantation, or continuation of a DOAC vsshort-term interruption of a DOAC (1-4days) in the perioperative period.

Protocols for perioperative management of direct oral anticoagulants in hospitals: opportunities for improvement

Objectives To investigate and describe the protocolized perioperative management in patient using Direct oral anticoagulants (DOACs) in Dutch hospitals. Methods Between August and December 2020, a nationwide survey in 70 hospitals in the Netherlands was conducted. We asked hospital pharmacists to submit their protocols for perioperative management of DOAC (apixaban, dabigatran, edoxaban and rivaroxaban) users. The protocols were assessed for a number of parameters divided into categories: interruption and restart timetables DOACs for elective procedures, criteria for the start of an urgent procedure without antidotes, criteria for the use of antidotes and advised antidotes for urgent procedures. Results A total of 49 hospitals (70%) sent a protocol for perioperative management of DOACs. Two pairs of protocols were identical because hospitals cooperated closely, leaving 47 individual protocols for analysis. Thirty-five of these protocols contained a policy for both elective and urgent procedure; five protocols contained only a policy for elective and seven only for urgent procedures. In protocols for elective procedure, we found great variation in interruption and restart timetables intended for patients with renal impairment (Estimated Glomerular Filtration Ratio < 80 ml/min). In case of urgent procedures, there is variation in choice of antidote, criteria for administration of an antidote and antidote dosing. Conclusion This study provides an overview of the current state of the perioperative protocols in the Netherlands in patients treated with direct oral anticoagulants. Protocols are often not complete and show important and unwanted variation. We have found that national guidelines do not provide unambiguous advice on all points (urgent procedures) and are therefore often elaborated at a local level. The results of this research can help in improving and harmonizing the perioperative protocols on a national level.

Peri-interventional management of platelet aggregation inhibition and anticoagulation in urology

Perioperative management of anticoagulation in patients receiving long-term anticoagulation or platelet aggregation inhibitors requires an individual consideration of competing risks. If the risk for bleeding is low, anticoagulation can often be continued. If it is necessary to pause anticoagulation, the necessity and dosage of bridging must be determined based on the individual risk of thromboembolism. Only patients with ahigh risk of thromboembolism should receive bridging in the full therapeutic dosage. The timing of pausing anticoagulation depends on the risk of bleeding from the urological intervention and the renal function of the patient. Platelet aggregation inhibitors should not be discontinued in the first month after coronary stent implantation, especially after acute coronary syndrome.

Perioperative management of patients with prosthetic heart valves-A narrative review.

ABSTRACTWorldwide, about 13% of the 200,000 annual recipients of prosthetic heart valves (PHV) present for various surgical procedures. Also, more and more females are opting for pregnancies after having PHV. All patients with PHV present unique challenges for the anesthesiologists, surgeons and obstetricians (in case of deliveries). They have to deal with the perioperative management of anticoagulation and a host of other issues involved. We reviewed the English language medical literature relevant to the different aspects of perioperative management of patients with PHV, particularly the guidelines of reputed societies that appeared in the last 20 years. Regression of cardiac pathophysiology following valve replacement is variable both in extent and timeline. The extent to which reverse remodeling occurs depends on the perioperative status of the heart. We discussed the perioperative assessment of patients with PHV, including focused history and relevant investigations with the inferences drawn. We examined the need for prophylaxis against infective endocarditis and management of anticoagulation in such patients in the perioperative period and the guidelines of reputed societies. We also reviewed the conduct of anesthesia, including general and regional anesthesia (neuraxial and peripheral nerve/plexus blocks) in such patients. Finally, we discussed the management of delivery in this group of high-risk patients. From the discussion of different aspects of perioperative management of patients with PHV, we hope to guide in formulating the comprehensive plan of management of safe anesthesia in such patients.

The Perioperative Management of Antiplatelet and Anticoagulant Drugs in Hip Fractures: Do the Surgery as Early as Possible.

Hip fractures are among the most common fractures operated by orthopedic surgeons. Many elderly patients, who account for a significant percentage of hip fractures, suffer from medical conditions requiring antiplatelet and anticoagulant administration. Meanwhile, considerable evidence recommends early surgery within 48b hours of admission. We aim to review the existing evidence regarding the perioperative management of antiplatelet and anticoagulant drugs in hip fractures. It was concluded that surgery for hip fractures in patients with antiplatelet drug consumption should not be delayed unless a clear contraindication exists. Active reversal strategies are indicated for patients with hip fractures and warfarin therapy. However, evidence for the safety of these agents in pregnancy, breastfeeding state, and adolescence has not yet been established. Little data exists about perioperative management of direct-acting oral anticoagulants in hip fractures. Early surgery after 12-24 hours of drug cessation has been suggested in studies; however, it should be employed cautiously. Despite extensive research, the importance of the issue necessitates additional higher-quality studies.

Postmastectomy Breast Reconstruction is Safe in Patients on Chronic Anticoagulation.

Background Postmastectomy breast reconstruction (PMR) increases patient satisfaction, quality of life, and psychosocial well-being. There is scarce data regarding the safety of PMR in chronic anticoagulated patients. Perioperative complications can reduce patient satisfaction; therefore, it is important to elucidate the safety of PMR in these patients. Methods A retrospective case–control study of patients who underwent PMR with implants and were on chronic anticoagulation was performed at our institution. Inclusion criteria were women ≥ 18 years old. Exclusion criteria included autologous reconstructions, lumpectomy, and oncoplastic procedures. Two controls for every one patient on anticoagulation were matched by age, body mass index, radiotherapy, smoking history, type of reconstruction, time of reconstruction, and laterality. Results From 2009 to 2020, 37 breasts (20 patients) underwent PMR with implant-based reconstruction and were on chronic anticoagulation. A total of 74 breasts (40 patients) who had similar demographic characteristics to the cases were defined as the control group. Mean age for the case group was 53.6 years (standard deviation [SD] = 16.1), mean body mass index was 28.6 kg/m 2 (SD = 5.1), and 2.7% of breasts had radiotherapy before reconstruction and 5.4% after reconstruction. Nine patients were on long-term warfarin, six on apixaban, three on rivaroxaban, one on low-molecular-weight heparin, and one on dabigatran. The indications for anticoagulation were prior thromboembolic events in 50%. Anticoagulated patients had a higher risk of capsular contracture (10.8% vs. 0%, p = 0.005). There were no differences regarding incidence of hematoma (2.7% vs. 1.4%, p = 0.63), thromboembolism (5% vs. 0%, p = 0.16), reconstructive-related complications, or length of hospitalization (1.6 days [SD = 24.2] vs. 1.4 days [SD = 24.2], p = 0.85). Conclusion Postmastectomy implant-based breast reconstruction can be safely performed in patients on chronic anticoagulation with appropriate perioperative management of anticoagulation. This information can be useful for preoperative counseling on these patients.

Management of Perioperative Anticoagulation in a Patient with Antiphospholipid Antibody Syndrome Undergoing Cardiac Surgery

Patients with Antiphospholipid syndrome (APLS) are at high risk for both bleeding and thrombotic complications during cardiac surgery involving cardiopulmonary bypass (CPB). In this case we present a patient with APLS and Immune Thrombocytopenic Purpura who successfully underwent aortic valve replacement (AVR) with CPB despite recent craniotomy for subdural hematoma evacuation. Anticoagulation for CPB was monitored by targeting an Activated Clotting Time (ACT) that was 2× the upper limit of normal. A multidisciplinary approach was essential in ensuring a safe and successful operation.

Perioperative Anticoagulation Management.

Management of anticoagulation in individuals undergoing operative procedures is a complex situation. Each case should be assessed individually with proper risk assessment, monitoring, and plan for perioperative and postoperative anticoagulation. Clinical evidence for the management of these patients is relatively scarce, and clinicians are often assessing each individual case with minimal guidance. This review provides nurses with a summary of available literature on the assessment, laboratory monitoring, timing of adjusting anticoagulation, and bridging prior to procedures. In addition to general perioperative anticoagulation management, this review discusses perioperative management in special populations and provides a summary on principles when anticoagulation should be resumed following a procedure.

Management of DOAC in Patients Undergoing Planned Surgery or Invasive Procedure: Italian Federation of Centers for the Diagnosis of Thrombotic Disorders and the Surveillance of the Antithrombotic Therapies (FCSA) Position Paper.

Patients on anticoagulant treatment are constantly increasing, with an estimated prevalence in Italy of 2% of the total population. About a quarter of the anticoagulated patients require temporary cessation of direct oral anticoagulants (DOACs) or vitamin K antagonists for a planned intervention within 2 years from anticoagulation inception. Several clinical issues about DOAC interruption remain unanswered: many questions are tentatively addressed daily by thousands of physicians worldwide through an experience-based balancing of thrombotic and bleeding risks. Among possible valuable answers, the Italian Federation of Centers for the diagnosis of thrombotic disorders and the Surveillance of the Antithrombotic therapies (FCSA) proposes some experience-based suggestions and expert opinions. In particular, FCSA provides practical guidance on the following issues: (1) multiparametric assessment of thrombotic and bleeding risks based on patients' individual and surgical risk factor, (2) testing of prothrombin time, activated partial thromboplastin time, and DOAC plasma levels before surgery or invasive procedure, (3) use of heparin, (4) restarting of full-dose DOAC after high risk bleeding surgery, (5) practical nonpharmacological suggestions to manage patients perioperatively. Finally, FCSA suggests creating a multidisciplinary “anticoagulation team” with the aim to define the optimal perioperative management of anticoagulation.

Periprocedural outcomes of protamine administration after catheter ablation of atrial fibrillation.

Perioperative anticoagulation management with uninterrupted or minimally interrupted anticoagulation during atrial fibrillation (AF) ablation is thought to be critical to minimize thromboembolic complications. Protamine is often administered to neutralize the effects of heparin and expedite vascular hemostasis post-procedure. We performed a systematic review and meta-analysis to determine the effectiveness of protamine to expedite vascular hemostasis and ambulation in patients undergoing AF ablation. Electronic searches on PubMed, The Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL databases from the inception through August 7, 2021, were performed. The primary outcomes included-time to hemostasis (minutes) and time to ambulation (minutes). The secondary outcomes included - any vascular complications (excluding minor hematoma), minor hematoma, or cerebrovascular accidents (CVA). A total of 5 eligible studies (3 retrospective cohort studies and two randomized trials) consisting of 1012 patients (515 patients received protamine group and 497 patients did not receive protamine group) were included in the meta-analysis. There was a significant reduction in time to ambulation [weighted mean difference (WMD) -176.6 minutes, 95% Confidence interval (CI) -266.9 to -86.3; p < 0.01] and time to hemostasis (WMD -13.72 minutes, 95% CI -22 to -5.4, p < 0.01) in the protamine group compared to the contrary. At a follow-up up to 3 months, there was no statistical difference between the two groups with regards to vascular complications (2.9% vs. 7.4%; Risk ratio (RR) 0.46 95% CI 0.17 to 1.24; p = 0.12), minor hematoma (2.1% vs. 5.8%; RR 0.43, 95% CI 0.16 to 1.2; p = 0.11) or CVA (0 vs. 0.3%; RR 0.62, 95% CI 0.08 to 4.98; p = 0.65). Protamine administration was associated with reduced time to ambulation (176 minutes reduction) and time to hemostasis (13 minutes reduction) without an increase in any adverse events.

Chronic subdural haematoma: the role of peri‐operative medicine in a common form of reversible brain injury

Epidemiological studies project a significant rise in cases of chronic subdural haematoma over the next 20 years. Patients with this condition are frequently older and medically complex, with baseline characteristics that may increase peri-operative risk. The intra-operative period is only a small portion of a patient's total hospital stay, with a majority of patients in the United Kingdom transferred between institutions for their surgical and rehabilitative care. Definitive management remains surgical, but peri-operative challenges exist which resonate with other surgical cohorts where multidisciplinary working has become the gold standard. These include shared decision-making, medical optimisation, the management of peri-operative anticoagulation and the identification of key points of equipoise for examination in the future trials. In this narrative review, we use a stereotyped patient journey to provide context to the recent literature, highlighting where multidisciplinary expertise may be required to optimise patient care and maximise the benefits of surgical management. We discuss the triage, pre-operative optimisation, intra-operative management and immediate postoperative care of patients undergoing surgery for a chronic subdural haematoma. We also discuss where adjunctive medical management may be indicated. In so doing, we present the current and emerging evidence base for the role of an integrated peri-operative medicine team in the care of patients with a chronic subdural haematoma.

Anticoagulant Treatment for Pediatric Infection-Related Cerebral Venous Thrombosis

BackgroundWe aimed to describe the clinical presentation, risk of bleeding and recurrent thrombosis, and perioperative anticoagulant management of children with cerebral venous thrombosis (CVT) and an associated head or neck infection. MethodsIn this subgroup analysis of the EINSTEIN-Jr study, we included children with CVT and an associated head or neck infection who received therapeutic anticoagulants with either low-molecular-weight heparin (with or without subsequent vitamin K antagonists) or rivaroxaban for a period of 3 months. Analyses are descriptive. ResultsOf 74 included children, 59 (80%) had otomastoiditis, 21 (28%) a central nervous system infection, 18 (24%) sinusitis, and 9 (12%) another upper respiratory tract infection; 29 (39%) had infection of multiple regions of the head or neck. All 74 children received antibiotics and therapeutic anticoagulants; 41 (55%) underwent surgery, of whom 34 were diagnosed with CVT preoperatively. Anticoagulation was started before surgery in 12 children and interrupted 0-1 days prior to surgery. Anticoagulation was (re)started in all 34 children at a median of 1 day (interquartile range: 0-1) postoperatively, in therapeutic doses in 94%. Overall, one child (1%, 95% confidence interval: 0-7) had recurrent thrombosis, and one (1%, 95% confidence interval: 0-7) had major bleeding; neither was associated with surgery. At 3 months, no children had died, 3 (4%) had persistent focal neurologic deficits, and 2 (3%) had impaired vision. ConclusionsChildren with CVT and an associated head or neck infection administered therapeutic anticoagulants generally had low risks of bleeding and thrombotic complications, including those who had surgical interventions with delay or interruption of anticoagulation.

Is there consensus on the perioperative management of Xa inhibitors in patients undergoing elective spine surgery?-A survey of current spine surgeon practices.

Factor Xa inhibitors (Xai) are an increasingly common consideration in perioperative anticoagulation management. However, there no existing guidelines established for use in Spine Surgery. This survey study aims to capture current practice trends regarding the perioperative management of Xai among spine surgeons. An 11-question survey was sent to all surgeon members of 3 spinal surgery societies. Responses were remitted anonymously. Questions characterized the background and experience of the respondent and inquired into their current perioperative Xai and other anticoagulant management. Questions were all single-best option, multiple-choice. A total of 116 surveys were received. Twenty-six (22.4%) were from neurosurgeons and 90 (77.6%) were from orthopedic surgeons. Practiced preoperative Xai hold length tended to be longer than recommended by the respondent's medical colleagues. Only 65.2% (P≤0.0001) of respondents practiced in agreement with the recommendations of their medical colleagues. Postoperative Xai holds trended toward longer holds than that of other anticoagulants with 37.9% (P=0.0125) of respondents showed differences within their own practice between length of Xai hold and length of other anticoagulant holds. One out of four respondents reported noticing a change in the rate of perioperative bleeding complications among Xai patients. Despite reported increased bleeding issues, only 39% of those who noted this increase in bleeding complications reported they would hold a Xai longer than other anticoagulants. There exists a wide range of recommended and practiced chronic anticoagulant hold lengths. This inconsistency likely highlights conflicting risk aversion among surgeons, between complications which are viewed as medical (i.e., thromboembolism and stroke) vs. surgical (i.e., compressive hematoma). Yet, survey responses suggest the length of Xai hold times did not necessarily reflect the surgeon's experience with postoperative bleeding complications in Xai patients. These inconsistent practices highlight the need for further research that can establish guidelines for perioperative management of Xai patients undergoing spine surgery. Anticoagulants; factor Xa inhibitors (factor Xai); spine; orthopedic surgery; neurosurgery.

Abstract 10572: Efficacy and Safety of Protamine After Catheter Ablation of Atrial Fibrillation: Systematic Review and Meta-Analysis

Introduction: Perioperative anticoagulation management with uninterrupted or minimally interrupted anticoagulation during atrial fibrillation (AF) ablation is thought to be critical to minimize thromboembolic complications. Protamine is often administered to neutralize the effects of heparin and expedite vascular hemostasis post-procedure. Hypothesis: To determine the efficacy and safety of protamine to expedite vascular hemostasis and ambulation in patients undergoing AF ablation. Methods: Electronic searches on PubMed, The Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL databases from the inception through June 7, 2021, were performed. The primary outcome was time to ambulate (minutes) and hemostasis (minutes). The secondary outcome was any vascular complications or minor hematoma or cerebrovascular accidents. Results: A total of 5 eligible studies consisting of 637 patients (Protamine group: 515 and no protamine group: 497) were included in the meta-analysis. There was a significant reduction in time to ambulation {mean difference (MD): -176.60, 95% CI -266.87 - -86.32; p&lt; 0.01} and in time to hemostasis between the two groups (MD -13.72, 95% CI -22.01 - -5.44, p&lt;0.01) in the protamine group. There were no differences in the rates of vascular complications (RR 0.46 95% CI 0.17-1.24 for any vascular complication; RR 0.43, 95% CI 0.16-1.2 for minor hematoma) or cerebrovascular accidents (RR 0.62, 95% CI 0.08 - 4.98) between the two groups. Conclusions: Protamine administration was associated with reduced time to ambulation (176 minutes reduction) and time to hemostasis (13 minutes reduction) without an increase in any adverse events.

Perioperative management of antithrombotic therapy: a case-based narrative review.

The periprocedural management of patients who are receiving vitamin K antagonists, direct oral anticoagulants and antiplatelet therapy is a common and challenging clinical scenario as the decision to interrupt or continue these medications is anchored on patient and procedure-related risks for bleeding and thrombosis. Adding to the complexity of clinical management is the fact that anticoagulants have varied pharmacokinetic and pharmacodynamic properties and indications for clinical use. In many minimal-bleed-risk procedures, anticoagulants can be safely continued, without interruption, whereas in cases where anticoagulants cannot be safely continued, the timing of interruption and resumption, as well as the need for heparin bridging requires consideration. Perioperative antithrombotic management scenarios occur most often in patients with atrial fibrillation, mechanical heart valves, coronary stents, and cerebrovascular disease as such patients are likely to be prescribed anticoagulant and/or antiplatelet therapy. The objective of this case-based narrative review is to provide a practical evidence-based approach to the perioperative management of patients on anticoagulation and antiplatelet therapy. Four clinical scenarios will be provided: (1) managing patients in whom anticoagulants can be continued; (2) perioperative management of direct oral anticoagulants; (3) management of patients on dual antiplatelet therapy; and (4) anticoagulant management for emergency or urgent surgery.

Perioperative Management of Oral Anticoagulation: A Real-World Observational Study

Aims:Using a retrospective study, we evaluated: the risk of thromboembolism and bleeding following the perioperative management of oral anticoagulants (OACs) and the adherence to the guidelines by the clinicians involved. Methods:Six hundred procedures, 120 for each OAC were collected from a Central Tuscany Surgery Department database. The endpoints were:the 30-days rate of arterial, venous thrombotic events and bleedings, classified by ISTH, and their association with adherence to EHRA guidelines. Results: Three hundreds and seventy one procedures(61%) were at high risk of bleeding. Until 30 days of follow-up, thrombotic events occurred in 4 patients, 7% total bleedings;12.8% of bleedings occurred in inappropriate heparin bridging and 5.7% in patients without bridging (p &lt;.016). Four hundred and forty two (73.7%) procedures were performed in complete adherence to guidelines. At the multivariate analysis inappropriate bridging (HR=2.3;95% CI 1.1-4.7; p=.021) and urologic interventions (HR=2.3;95% CI 1.2-4.4;p=.01) were independent risk factors for bleeding events. Conclusions: Bleedings were significantly correlated with inappropriate heparin bridging even if occurred also in correct management of OACs, being related to the major surgery itself.

Management of patients receiving novel antithrombotic treatment in endodontic practice: Review and clinical recommendations

Cardiovascular diseases are a major component of non-communicable diseases and death, with thrombosis constituting the most common underlying pathosis of the three major cardiovascular disorders: ischaemic heart disease (acute coronary syndrome), stroke and venous thromboembolism (VTE). The introduction of direct oral anticoagulants (DOACs) in recent years has necessitated a more complex approach to periprocedural and perioperative anticoagulation management and the need for revised management strategies and protocols. Currently, patients taking classic oral anticoagulants are advised to stop taking the drugs and have their INR values checked 72h prior to dental surgery (e.g., apical surgery, tooth extraction, and periodontal surgery) and checked again 24h prior to the procedure to ensure it is within the therapeutic range. However, the current incorporation of these novel DOACs in routine medical practice requires changes in the way patients are managed preoperatively in dentistry, and specifically in endodontic surgery. The methodology applied in this review included searching for relevant articles in the PubMed database using keywords listed in the Entree Terms databases. Articles published on human blood clotting mechanism, antithrombotic drugs, as well as treatment guidelines and recommendations for dentistry were retrieved. In addition, textbooks and guidelines that may not have surfaced in the online search were searched manually. The aim of this paper was to review the mechanisms of action of classic and novel antithrombotic medications and their impact on endodontic treatment and the management of local haemostasis in endodontics.

Update on the perioperative management of antiplatelets and anticoagulants in ophthalmic surgery.

Anti-thrombotic drugs (antiplatelets and anticoagulants) are widely used for different clinical reasons. This means that there are an increasing number of patients undergoing elective ophthalmic surgery that are being treated with these drugs. A better knowledge of their implications and their peri-operative use may help to prevent surgical and secondary adverse events. There is often no firm recommendation on how to manage certain drugs in certain surgeries. To review the recommendations in the scientific literature as regards managing anti-thrombotic agents during the peri-operative period of ophthalmic surgery. A review was made of the relevant guidelines and studies using an antiplatelet and anticoagulant drugs approach for cataract, vitreo-retinal, glaucoma, oculoplastic, and strabismus surgeries. Recommendations about whether to continue or discontinue anti-thrombotic drugs in the peri-operative period of different ophthalmic surgical fields are presented. There are only firm recommendations of maintaining anti-thrombotic drugs as regards cataract surgery using phacoemulsification with topical anaesthesia. In other surgical fields, ophthalmologists should balance the risk of thromboembolic events and risks of haemorrhagic complications in order to carry out a proper management. A multi-disciplinary approach is recommended for complex cases. Additional studies should be performed to better characterise the peri-operative use of anti-thrombotic agents in order to prepare clinical guidelines for ophthalmic surgery.

Cardiac Surgery in a Patient With Antiphospholipid Syndrome and Heparin-Induced Thrombocytopenia

ANTIPHOSPHOLIPID SYNDROME (APS) and heparin-induced thrombocytopenia (HIT) are separate disease processes that are both characterized by a prothrombotic state and an increased risk of perioperative complications. APS is a rare, noninflammatory, autoimmune disease, resulting in arterial and/or venous thrombosis, thrombocytopenia, fetal loss, and the presence of antiphospholipid (APL) antibodies. 1 Mishra PK Khazi FM You P et al. Severe antiphospholipid syndrome and cardiac surgery: Perioperative management. Asian Cardiovasc Thorac Ann. 2016; 24: 473-476 Crossref PubMed Scopus (4) Google Scholar The incidence of APS is approximately 2% in the general population. 2 Koniari I Siminelakis SN Baikoussis NG et al. Antiphospholipid syndrome: Its implication in cardiovascular diseases: A review. J Cardiothorac Surg. 2010; 5: 101 Crossref PubMed Scopus (72) Google Scholar Irregular thickening of heart valves from immune-complex deposition leads to valvular disease in 35% to 82% of patients with APS, and 4% to 6% of these patients require surgical intervention. 3 Berkun Y Elami A Meir K et al. Increased morbidity and mortality in patients with antiphospholipid syndrome undergoing valve replacement surgery. J Thorac Cardiovasc Surg. 2004; 127: 414-420 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar The mitral valve is the most commonly affected, followed by the aortic valve. 1 Mishra PK Khazi FM You P et al. Severe antiphospholipid syndrome and cardiac surgery: Perioperative management. Asian Cardiovasc Thorac Ann. 2016; 24: 473-476 Crossref PubMed Scopus (4) Google Scholar Due to the prothrombotic state, valve surgery mortality rates are as high as 10% to 20%, 4 Nakajima T Enomoto Y Ishigaki M et al. Perioperative anticoagulation management during aortic valve replacement complicated by antiphospholipid syndrome. J Card Surg. 2017; 32: 633-635 Crossref PubMed Scopus (4) Google Scholar and surgical intervention usually is deferred to medical management if possible. 5 Erkan D Yazici Y Sobel R et al. Primary antiphospholipid syndrome: Functional outcome after 10 years. J Rheumatol. 2000; 27: 2817-2821 PubMed Google Scholar

The Use of Extracorporeal Membrane Oxygenation in Severely Burned Patients: A Survey of North American Burn Centers.

Respiratory failure and acute respiratory distress syndrome can occur in burn patients with or without inhalational injury and can significantly increase mortality. For patients with severe respiratory failure who fail conventional therapy with mechanical ventilation, the use of venovenous extracorporeal membrane oxygenation (ECMO) may be a life-saving salvage therapy. There have been a series of case reports detailing the use of ECMO in burn patients over the last 20 years, but very little is currently known about the status of ECMO use at burn centers in North America. Using a web-based survey of burn center directors in Canada and the United States, we examined the rate of usage of ECMO in burn care, barriers to its use, and the perioperative management of burn patients receiving ECMO therapy. Our findings indicate that approximately half of the burn centers have used ECMO in the care of burn patients, but patient volume is very low on average (less than 1 per year). Of centers that do use ECMO in burn care, only 40% have a specified protocol for doing so. Approximately half have operated on patients being actively treated with ECMO therapy, but perioperative management of anticoagulation varies widely. A lack of experience and institutional support and a perceived lack of evidence to support ECMO use in burn patients were the most commonly identified barriers to more widespread uptake. Better collaboration between burn centers will allow for the creation of consensus statements and protocols to improve outcomes for burn patients who require ECMO.