Pre-existing Anticoagulation Research Articles

Anticoagulant Medication in Endoprosthetically Treated Proximal Femur Fracture - Complications and Mortality Considering the Time of Treatment as a Quality Criterion.

There is an international debate on the optimal time to surgery following hip fracture in older patients. Pre-existing anticoagulation seems to be a major concern when it comes to a delay in operative fracture treatment. The aim of this study was to examine complication and mortality rates for elderly anticoagulated hip fracture patients considering early (<24h) vs. delayed (>24h) surgery.Our Analysis is based on data of the external inpatient quality assurance of North Rhine Westphalia as the most populous German federal state. We identified 13,201 hip fracture patients with antithrombotic medication and a minimum age of 65 years treated from January 2015 to December 2017.Delayed surgery was associated with significantly higher rates of general and surgical complications as well as mortality. Except for pre-existing heart failure, we were not able to identify certain comorbidities that could clearly indicate, why there might have been a delay.In most cases, patients with antithrombotic medication have a poor outcome to be expected due to serious comorbidity. If there was a delay in surgery for those patients, treatment results were even worse. Thus, surgery with a delay of >24h must be avoided to reduce the risk of complications.

Continuous arterial blood pressure indices and early hematoma expansion in patients with spontaneous intracerebral hemorrhage

BackgroundBlood pressure variability (BPV) and its potential association with early hematoma expansion (HE) in intracerebral hemorrhage (ICH) remains to be fully elucidated. Our study explores the potential link between BPV within the first 24 h after admission and HE in ICH. MethodsIn a prospective cohort single-center study, we analyzed consecutive patients with spontaneous ICH. Continuous BP data via an arterial line extracted from the Intellispace Critical Care and Anesthesia information system (Philips Healthcare) were analyzed over 0–2, 0–8, 0–12, and 0–24 h intervals post-admission. BPV was assessed through successive variability (SV), standard deviation (SD), and coefficient of variation (CV) using all available BP measurements. Early HE was defined as an absolute [≥ 6 ml] or relative [≥ 33 %] increase in ICH volume on 24-hours follow-up brain imaging. Secondary endpoints were the influence of BP on admission and other potential risk factors for HE. ResultsAmong 305 ICH-patients (mean age ± SD 70.1 ± 14.9 years, 47.9 % female, median NIHSS 6 (3, 13), median ICH score 1 (1, 2)), 41 (13.4 %) experienced HE. HE-patients had higher NIHSS (p = 0.015), ICH-score (p = 0.005), ICH volume (p < 0.001) and higher pre-anticoagulation treatment (p = 0.004) on admission. There was no difference in BPV comparing ICH-patients with HE to those without. However, patients with HE had significantly lower diastolic BP (76.6 ± 14.8 vs. 86.3 ± 19.7 mmHg, p = 0.005) and MAP (103.2 ± 22.4 vs. 112.2 ± 22.6, p = 0.027) on admission. This pattern of lower diastolic BP persisted across the first 24 h. Logistic regression revealed larger ICH volume and pre-existing anticoagulation as significant predictors of HE, with higher initial diastolic BP reducing HE risk. Hemorrhages ≥ 30 cm3 showed significantly lower initial diastolic BP, MAP, and BPV across all time frames compared to ICH < 30 cm3. ConclusionsBPV within the first 24 h was not associated with HE. Lower diastolic BP on admission, anticoagulation use, and larger ICH volume are potential predictors for HE. However, larger hemorrhage size (>30 cm3) experienced lower absolute BP and BPV indices and worse clinical outcomes. These findings suggest a nuanced relationship between BP dynamics and ICH severity, underscoring the need for individualized BP management in acute ICH care. Further research is necessary to explore these relationships and optimize treatment strategies.

Does tranexamic acid have a positive effect on the outcome of older multiple trauma patients on antithrombotic drugs? An analysis using the TraumaRegister DGU®.

BackgroundAcute hemorrhage is one of the most common causes of death in multiple trauma patients. Due to physiological changes, pre-existing conditions, and medication, older trauma patients are more prone to poor prognosis. Tranexamic acid (TXA) has been shown to be beneficial in multiple trauma patients with acute hemorrhage in general. The relation of tranexamic acid administration on survival in elderly trauma patients with pre-existing anticoagulation is the objective of this study. Therefore, we used the database of the TraumaRegister DGU® (TR-DGU), which documents data on severely injured trauma patients.MethodsIn this retrospective analysis, we evaluated the TR-DGU data from 16,713 primary admitted patients with multiple trauma and age &amp;gt; =50 years from 2015 to 2019. Patients with pre-existing anticoagulation and TXA administration (996 patients, 6%), pre-existing anticoagulation without TXA administration (4,807 patients, 28.8%), without anticoagulation as premedication but TXA administration (1,957 patients, 11.7%), and without anticoagulation and TXA administration (8,953 patients, 53.6%) were identified. A regression analysis was performed to investigate the influence of pre-existing antithrombotic drugs and TXA on mortality. A propensity score was created in patients with pre-existing anticoagulation, and matching was performed for better comparability of patients with and without TXA administration.ResultsRetrospective trauma patients who underwent tranexamic acid administration were older and had a higher ISS than patients without tranexamic acid donation. Predicted mortality (according to the RISC II Score) and observed mortality were higher in the group with tranexamic acid administration. The regression analysis showed that TXA administration was associated with lower mortality rates within the first 24 h in older patients with anticoagulation as premedication. The propensity score analysis referred to higher fluid requirement, higher requirement of blood transfusion, and longer hospital stay in the group with tranexamic acid administration. There was no increase in complications. Despite higher transfusion volumes, the tranexamic acid group had a comparable all-cause mortality rate.ConclusionTXA administration in older trauma patients is associated with a reduced 24-h mortality rate after trauma, without increased risk of thromboembolic events. There is no relationship between tranexamic acid and overall mortality in patients with anticoagulation as premedication. Considering pre-existing anticoagulation, tranexamic acid may be recommended in elderly trauma patients with acute bleeding.

Hemoperfusion in anesthesia and intensive care medicine: benefits, risks, and evidence for different systems

Hemoperfusion is atechnique for the extracorporeal elimination of endogenous and exogenous toxins and harmful mediators by adsorption. It can be used as astand-alone device, as part of aheart-lung machine or extracorporeal membrane oxygenation (ECMO) or, as is currently the case, integrated into akidney replacement procedure. In the meantime, various suppliers offer devices with different technologies. The aim of this work was to evaluate the benefits, risks and evidence of the different systems, how they work and for which indications they are approved in Germany. To achieve this goal, anarrative assessment of the existing literature and guidelines for different indications was performed. The focus was on in vivo studies. In principle, adistinction must be made in adsorption techniques between pure adsorption and the combination as adsorption and kidney replacement therapy. The adsorbers available in Germany include Cytosorb®, HA-330, Seraph®-100 and Toraymyxin. Combined procedures (adsorption and kidney replacement) are offered with coupled plasma filtration and adsorption (CPFA) and oXiris®. Most adsorbers have been developed for cytokine and endotoxin removal in patients with sepsis; however, to date, no randomized controlled trial (RCT) has demonstrated asurvival benefit when using hemoperfusion. Therefore, the S3 guidelines for treatment of sepsis and the surviving sepsis campaign guidelines advise against its routine use. When the corona pandemic began, hemoperfusion was considered as apromising therapeutic approach. Cytosorb®, Seraph®-100, and oXiris® received emergency approval by the FDA to be used in critically ill patients with COVID-19, so questions arose about the appropriateness and importance of its use; however, the data generated did not show positive results, so its use cannot be recommended routinely either. In addition, they are not mentioned as atreatment option in the current guidelines. The use of adsorption procedures in patients with liver failure and rhabdomyolysis has only been rudimentarily studied, so any evidence is currently lacking. The only adsorber that has CE approval in Germany for both applications is Cytosorb®. In the next few years, studies will have to follow that investigate the efficacy and thus either justify or refute the use in clinical routine. Hemoperfusion procedures are used in the heart-lung machine as part of cardiac surgery for either cytokine or anticoagulant adsorption. No congruent data are available to support the use for the elimination of cytokines. If emergency cardiac surgery is required in apatient with pre-existing anticoagulation, hemoperfusion procedures can be used to prevent bleeding complications. Cytosorb® has CE approval for this indication. All available techniques are nonselective adsorption processes, so that adsorption of known and unknown substances can occur. Unintentional adsorption of drugs, such as various anti-infective agents is arelevant risk, especially when used in patients with sepsis. Various adsorption systems can eliminate different known and unknown substances. Currently, there is alack of evidence for all indications and systems to justify their routine use except in clinical trials. Future clinical trials should evaluate the potential benefits but also dangers, so that in the meantime the routine use can be justified or arecommendation against the use can be given.

Preexisting anticoagulation is an independent predictor of mortality in geriatric trauma patients - a retrospective cohort study.

Preexisting anticoagulation is common among geriatric trauma patients. Geriatric trauma patients have a higher risk of mortality compared to younger patients. We sought to evaluate the association of preexisting anticoagulation with mortality in a group of geriatric trauma patients. A retrospective review of geriatric trauma patients was conducted for those admitted to a Level 1 trauma center from January 2018 to December 2020. Vital signs, demographics, injury characteristics, laboratory data, and mortality were all collected. Multivariable logistic regression analysis was performed for the association of preexisting anticoagulation and a primary endpoint of all-cause mortality. These groups were controlled for preexisting comorbidities, injury severity scores, and systolic blood pressure in the emergency department. Four thousand four hundred thirty-two geriatric patients were admitted during the study period. This cohort was made up of 36.9% men and 63.1% women. Three thousand eight hundred fifty-nine (87.2%) were white; the average age was 81±8.5 years, and the median injury severity score (ISS) was 5. The mean systolic blood pressure was 150±32mmHg, mean heart rate was 81±16bpm, mean lactate was 2.3±1.3, mean hematocrit was 37.3±8.8, and mean international normalized ratio (INR) was 1.7±10.3. One thousand five hundred ninety-two (35.9%) patients were on anticoagulation (AC) upon presentation. One hundred and sixty-five (3.7%) mortalities were recorded. Multivariable logistic regression analysis results show that preexisting anticoagulation [ odds ratio (OR) 1.92, 95% CI 1.36-2.72] was independently predictive of death. The analysis was adjusted for systolic BP in the emergency department less than90mmHg (OR 5.55, 95% CI 2.83-10.9), having more than 1 comorbidity (OR 2.30, 95% CI 1.57-3.38) and ISS (OR 1.13, 95% CI 1.10-1.15). Our study indicates that preexisting anticoagulation is associated with mortality among geriatric trauma patients.

Atrial Fibrillation Detected before or after Stroke: Role of Anticoagulation.

Atrial fibrillation (AF) known before ischemic stroke (KAF) has been postulated to be an independent category with a recurrence risk higher than that of AF detected after stroke (AFDAS). However, it is unknown whether this risk difference is confounded by pre-existing anticoagulation, which is most common in KAF and also indicates a high ischemic stroke recurrence risk. Individual patient data analysis from 5 prospective cohorts of anticoagulated patients following AF-associated ischemic stroke. We compared the primary (ischemic stroke recurrence) and secondary outcome (all-cause death) among patients with AFDAS versus KAF and among anticoagulation-naïve versus previously anticoagulated patients using multivariable Cox, Fine-Gray models, and goodness-of-fit statistics to investigate the relative independent prognostic importance of AF-category and pre-existing anticoagulation. Of 4,357 patients, 1,889 (43%) had AFDAS and 2,468 (57%) had KAF, while 3,105 (71%) were anticoagulation-naïve before stroke and 1,252 (29%) were previously anticoagulated. During 6,071 patient-years of follow-up, we observed 244 recurrent strokes and 661 deaths. Only pre-existing anticoagulation (but not KAF) was independently associated with a higher hazard for stroke recurrence in both Cox and Fine-Gray models. Models incorporating pre-existing anticoagulation showed better fit than those with AF category; adding AF-category did not result in better model fit. Neither pre-existing anticoagulation nor KAF were independently associated with death. Our findings challenge the notion that KAF and AFDAS are clinically relevant and distinct prognostic entities. Instead of attributing an independently high stroke recurrence risk to KAF, future research should focus on the causes of stroke despite anticoagulation to develop improved preventive treatments. ANN NEUROL 2023;94:43-54.

Acute Haemostatic Depletion and Failure in Patients with Traumatic Brain Injury (TBI): Pathophysiological and Clinical Considerations.

Because of the aging population, the number of low falls in elderly people with pre-existing anticoagulation is rising, often leading to traumatic brain injury (TBI) with a social and economic burden. Hemostatic disorders and disbalances seem to play a pivotal role in bleeding progression. Interrelationships between anticoagulatoric medication, coagulopathy, and bleeding progression seem to be a promising aim of therapy. We conducted a selective search of the literature in databases like Medline (Pubmed), Cochrane Library and current European treatment recommendations using relevant terms or their combination. Patients with isolated TBI are at risk for developing coagulopathy in the clinical course. Pre-injury intake of anticoagulants is leading to a significant increase in coagulopathy, so every third patient with TBI in this population suffers from coagulopathy, leading to hemorrhagic progression and delayed traumatic intracranial hemorrhage. In an assessment of coagulopathy, viscoelastic tests such as TEG or ROTEM seem to be more beneficial than conventional coagulation assays alone, especially because of their timely and more specific gain of information about coagulopathy. Furthermore, results of point-of-care diagnostic make rapid "goal-directed therapy" possible with promising results in subgroups of patients with TBI. The use of innovative technologies such as viscoelastic tests in the assessment of hemostatic disorders and implementation of treatment algorithms seem to be beneficial in patients with TBI, but further studies are needed to evaluate their impact on secondary brain injury and mortality.

Do Admitted COVID-19-Positive Patients on Anticoagulation Therapy Have a Reduced Hospital Stay and Disease Severity?

BackgroundAs of December 2021, the coronavirus disease 2019 (COVID-19) pandemic has resulted in the deaths of over 5 million people. It is known that infection with this virus causes a state of hypercoagulability. Because of this, there has been considerable debate on whether or not patients should be placed on anticoagulation prophylaxis/therapy. The goal of our project was to shed light on this topic by examining the effects of preexisting anticoagulation therapy in COVID-19 patients on disease severity (measured by blood clot readmissions, transfusion counts, and length of hospital stay). In this retrospective cohort study, we conducted an analysis based on data from 30,076 COVID-19-positive patients’ electronic medical records.Materials and methodsThis is a retrospective cohort study. Patients included in this study were identified from the HCA Healthcare corporate database. Registry data was sourced from HCA East Florida hospitals. All patients included in this study were COVID-19 positive via polymerase chain reaction (PCR) or rapid antigen testing on admission and over age 18. A total of 30,076 patients were included in this study with hospital admission dates from March 1, 2020 to June 30, 2021. The analysis examined the relationship between age, sex, blood clot history, and most importantly current anticoagulation status on COVID-19 disease severity (through blood clot readmissions, length of stay, and transfusion count). Blood clot readmissions were analyzed with a logistic regression model while the length of hospital stay and transfusion count were analyzed with a linear regression model.ResultsOur analysis revealed that the odds of experiencing a blood clot readmission is 2.017 times more likely in patients already on anticoagulation therapy compared to those who were not (p = 0.0024). We also found that patients on anticoagulation therapy had a hospital stay of 6.90 days longer on average than patients not on anticoagulation therapy (p < 0.0001). Finally, patients on anticoagulation therapy had, on average, 0.20 more blood transfusions than patients not on anticoagulation therapy (p < 0.001). ConclusionWhile these findings may be affected by the underlying conditions of those on preexisting anticoagulation therapy, they provide valuable insight into the debate on whether COVID-19-positive patients should be anticoagulated on admission to a hospital.

Does Pre-existing Anticoagulation or Antiplatelet Therapy Increase the Risk of Traumatic Subarachnoid Hemorrhage Progression?

Isolated traumatic subarachnoid hemorrhage (tSAH) is a common finding in mild traumatic brain injury that often results in transfer to a tertiary center. Patients prescribed blood-thinning medications (BTs) are believed to be at higher risk of clinical or radiographic worsening. To compare the rates of radiographic progression and need for neurosurgical intervention in patients with tSAH who are on anticoagulation (AC) and antiplatelet (AP) therapies with those who are not. Analysis using a retrospective cohort design identified patients older than 18 years with isolated tSAH and a Glasgow Coma Scale of 15 on admission. Clinical information including use of BTs, administration of reversal agents, radiographic progression, and need for neurosurgical intervention was collected. Patients on BTs were divided into AP, AC, and AP/AC groups based on drug type. Three hundred eighty-four patients were included with 203 in the non-BT group and 181 in the BT group. Overall, 2.1% had worsening scans, and none required operative intervention. There was no difference in radiographic worsening between the non-BT and BT groups (2.4% vs 1.6%; P = 1.00). Crosswise comparison revealed no difference between the non-BT group and each BT subtype (AP, AP/AC, or AC). The non-BT group was more likely to have radiographic improvement than the BT group (45.8% vs 30.9%; P = .002). Neurologically intact patients on BTs with isolated tSAH are not at increased risk of radiographic progression or neurosurgical intervention. The presence of BTs should not influence management decisions for increased surveillance.

Practice of pharmaceutical thrombosis prophylaxis and anticoagulation in patients with sepsis and pre-existing anticoagulation or heparin-induced type II thrombocytopenia-Results of a nationwide survey in German intensive care units

HintergrundSowohl eine vorbestehende Antikoagulation als auch prädisponierende Vorerkrankungen für Thromboembolien stellen ein häufiges Problem bei Patienten mit Sepsis dar, wenngleich der Umgang mit diesen Rahmenbedingungen von den aktuellen nationalen und internationalen Leitlinien für Sepsis und septischen Schock nicht adressiert wird. Ein Ziel der hier vorliegenden deutschlandweiten Umfrage war es, den Umgang von Intensivmedizinern mit derartigen Problemen zu eruieren.MethodenVon Oktober 2019 bis Mai 2020 führten wir eine deutschlandweite Umfrage unter ärztlichen Leitern von Intensivstationen zum Thema Antikoagulation und medikamentöser Thromboseprophylaxe bei Sepsis und Sepsis-induzierter Koagulopathie durch. Ein Fokus war hierbei, das Vorgehen bei Patienten mit vorbestehender Indikation zur therapeutischen Antikoagulation sowie bei vorbekannter Heparin-induzierter Thrombopenie Typ II (HIT-II) (akut-symptomatisch vs. Jahre zurückliegend) zu eruieren.ErgebnisseDie Umfrageergebnisse zeigen, dass auf den meisten der teilnehmenden Intensivstationen eine vorbestehende Antikoagulation größtenteils mit niedermolekularen Heparinpräparaten oder unfraktioniertem Heparin fortgeführt wird. Bei bekannter HIT-II wird Argatroban bevorzugt, unabhängig davon, ob es sich um eine Jahre zurückliegende oder eine akut-symptomatische HIT-II handelt. Eine hohe Variabilität besteht bei der Festlegung der Zielwerte für die Antikoagulation, wobei diese größtenteils deutlich über dem Bereich einer reinen venösen Thromboembolie(VTE)-Prophylaxe zu liegen kommen.SchlussfolgerungDie Datenlage zur Fortführung einer über die reine VTE-Prophylaxe hinausgehenden Antikoagulation mit konsekutiv erhöhtem Blutungsrisiko bei Patienten mit Sepsis und septischem Schock ist eingeschränkt, und Therapieentscheidungen unterliegen in vielen Fällen einer individuellen Abwägung des Behandlungsteams. Die Ergebnisse unserer Umfrage implizieren die Notwendigkeit einer systematischen Aufarbeitung dieses Themenfeldes, um die auf vielen Intensivstationen gelebte Praxis mit der gebotenen Evidenz zu unterlegen.Zusatzmaterial onlineDie Online-Version dieses Beitrags (10.1007/s00101-021-01011-9) enthält weitere Tabellen, Abbildungen und Auswertungen der Fragebögen.Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein oder nutzen Sie den QR-Code auf der ersten Seite des Artikels. Das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Infectious Endocardity and cerebral vascular accident in hospital university Ibn Rochd Casablanca (about 101 patients)

The association of stroke and infectious endocarditis is very common, mainly infections of the valves on the left side. The introduction of anticoagulation in the case of left-sided infective endocarditis is controversial, as it is unclear whether anticoagulation has an impact on the risk of stroke and hemorrhage in this population. The objective of this study was to assess the effect of anticoagulation on the onset of stroke and bleeding complications in patients with left-sided infective endocarditis. We included infectious endocarditis patients on the left side diagnosed in the cardiology department of CHU Ibn Rochd Casablanca over a period spread from January 2014 to January 2019. The inclusion criterion was the administration of therapeutic anticoagulation before admission. The assessment of these patients was based on the occurrence of a 10-week imaging-confirmed stroke. 101 patients with left-sided infectious endocarditis were identified. The subjects on anticoagulants (n-32) were older (median age 61 vs. 43), more likely to have a history of atrial fibrillation (18% vs. 3%), more often wearing valvular prostheses (23% vs. 7%) and had a lower incidence of mitral valve involvement (29% vs. 41%). There was no significant difference in the occurrence of stroke, cerebrovascular hemorrhage, or 10-week mortality between the 2 cohorts. Pre-existing anticoagulation has no effect on the occurrence of stroke, cerebrovascular hemorrhage or mortality in patients with left-sided infective endocarditis within 10 weeks.

Approaches to atrial fibrillation with tachycardia transition

Atrial fibrillation, the most common cardiac arrhythmia in the daily clinical routine, is achallenge in in-hospital and prehospital emergency medicine and is associated with increased morbidity and mortality if left untreated. Especially tachyarrhythmia, caused by atrial fibrillation, leads to various unspecified symptoms and in some cases to severely impaired circulation. Thus, an individualized therapeutic regimen is required. A fundamental distinction between rhythm control and rate control strategies must be made. In symptomatic but hemodynamically stable patients rate control is the method of choice. This applies in particular to patients with no pre-existing anticoagulation, especially if left atrial thrombi are not excluded. In hemodynamically unstable patients, considering the potential complications of sedation, electrical cardioversion is preferred. Pharmacological therapy of atrial fibrillation has to be divided into AV conduction modulating drugs-like short- or long-acting β‑blockers, calcium antagonists or cardiac glycosides-and the heterogeneous group of antiarrhythmic drugs aiming for rhythm control. Pulmonary vein ablation is the current long-term treatment of choice for symptomatic drug-refractory atrial fibrillation.

The Diagnosis and Treatment of Acute Traumatic Bleeding and Coagulopathy.

Uncontrolled bleeding with trauma-induced coagulopathy (TIC) is still the most common avoidable cause of death in multiple trauma. The aging of the population has led to an increasing number of bleeding trauma patients with pre-existing anticoagulation. Such patients are not treated uniformly, even in major trauma centers. This review is based on a selective search of the literature (Medline/PubMed, Cochrane Reviews) and summarizes current treatment recommendations, including those of the newly revised European trauma guidelines. The treatment of traumatic hemorrhage begins at the site of the accident, with compression, tourniquets, pelvic binders, and rapid transport to a certified trauma center. The early use of tourniquets was shown to lessen the trans- fusion requirement (packed red blood cells: 2.0 ± 0.1 vs. 9.3 ± 0.6; p < 0.001; fresh frozen plasma concentrates: 1.4 ± 0.08 vs. 6.2 ± 0.4; p < 0.001), while external pelvic stabilization was shown to reduce mortality (19.1% vs. 33.3%). Upon the patient's arrival in the hospital, steps are taken to measure, monitor, and support clotting function. Bleeding is controlled surgically according to the principles of damage control. Modern clotting management consists of goal-oriented, individualized therapy, including the use of point-of-care viscoelastic test procedures. Idarucizumab can be used as an antidote to the thrombin inhibitor dabigatran, andexanet alpha as an antidote to factor Xa inhibitors. The evidence-based treatment of patients with hemorrhage from severe trauma, in accordance with the existing guidelines, can improve the clinical outcome. Corresponding algorithms, adapted to local logistics and infrastructure, must be developed and implemented.

Management of pre-existing anticoagulation for timely treatment of proximal femoral fractures

Proximal femoral fractures are urgent indications for surgery. In cases of delayed surgical treatment more than 48 h after hospital admittance, increased rates of general complications, local complications and mortality have been proven. Since 2015, the quality target for the external quality assurance by order of the Federal Joint Committee (G-BA) is surgical treatment within 24 h after hospital admittance for osteosynthesis and within 48 h for joint replacement. The foundations for these time intervals are the S2e guidelines for the treatment of femoral neck fractures of adults from the German Society of Trauma Surgery (DGU) and the Austrian Society of Trauma Surgery (ÖGU) and several other international guidelines. The distinction of the temporal specifications between osteosynthesis and joint replacement in Germany is unusual in comparison with other countries. For 15% of each group of patients aprolonged preoperative preparation is accepted. In the structured dialog within the external quality management anticoagulants are quoted as the most frequent reason for delayed surgery. The present review provides away to achieve compliance with statutory provisions, to minimize the risks of both bleeding and thromboembolism and to achieve surgical treatment of proximal femoral fractures within the agreed time limit.

Abstract 97: Pre-Existing Anticoagulation Does Not Affect Stroke Rates in Patients With Left Sided Infective Endocarditis

Introduction: Stroke is a devastating and relatively frequent complication of infective endocarditis (IE), especially infection involving left-sided valves. Management of anticoagulation (AC) in left sided IE (LSIE) is controversial as it is unclear whether or not AC impacts stroke risk in this population. Current guidelines are equivocal on their recommendations regarding AC management. The objective of this study was to evaluate the effect of AC on neurologic outcomes in patients with LSIE. Methods: All patients admitted to a tertiary academic hospital in North Carolina, with a diagnosis of left sided IE between December 2011 and April 2018 were identified. Patients were stratified based on the receipt of therapeutic AC. The primary outcome measure was the rate of radiographically confirmed stroke at 10 weeks. Relevant data were analyzed with univariate and multivariate analysis. Results: Two-hundred and fifty-eight consecutive patients with LSIE were identified. Individuals receiving AC (n=50) were older (median age of 63 vs 52, p = 0.02) more likely to have a history of atrial fibrillation (34% vs 5%, p &lt; 0.01), had more prosthetic valve IE (38% vs 10.1%, p &lt;0.01) and had lower incidence of mitral valve IE (40% vs 62%, p &lt; 0.01). There was no significant difference in the rate of stroke, cerebrovascular hemorrhage, or mortality at ten weeks between the two cohorts. Mitral valve involvement (OR 2.20, 95CI 1.25-3.988) and intravenous drug use within 3 months of presentation (OR 2.10, 95CI 1.11-3.95) were identified as independent risk factors for stroke. Conclusions: AC therapy did not appear to have an effect on stroke in patients with LSIE. Furthermore, use of AC did not result in a greater occurrence of cerebrovascular hemorrhage or increased mortality. Continuation of AC in patients with a pre-existing indication should be considered in patients with LSIE in the absence of other contraindications. More robust studies are warranted to substantiate this recommendation.

Cardioverting acute atrial fibrillation and the risk of thromboembolism: not all patients are created equal

Current guidelines support the well-established clinical practice that patients who present with atrial fibrillation (AF) of less than 48hours duration should be considered for cardioversion, even in the absence of pre-existing anticoagulation. However, with increasing evidence that short runs of AF confer significant risk of stroke, on what evidence is this 48-hour rule based and is it time to adopt a new approach? We review existing evidence and suggest a novel approach to risk stratification in this setting. Overall, the risk of thromboembolism associated with acute cardioversion of patients with AF that is estimated to be of <48hours duration is low. However, this risk varies widely depending on patient characteristics. From existing evidence, we show that using the CHA2DS2-VASc score may allow better selection of appropriate patients in order to prevent exposing specific patient groups to an unacceptably high risk of a potentially devastating complication.

Clinical Implications of Crosstalk Between Coagulation and Inflammation: The Role of Anticoagulation in Treating Sepsis

BACKGROUNDDespite decades of active investigation, sepsis remains one of the leading causes of mortality worldwide. Multiple lines of evidence have illustrated that up-regulation of the activated Factor VII (FVIIa)/Tissue Factor (TF) complex, and its downstream extrinsic coagulation cascade, are major contributors to coagulopathies and inflammatory response during sepsis. For example, decreased mortality and inflammatory responses during sepsis were observed in mice with significantly reduced FVII expression. Another recent study demonstrated the association of increased mortality with higher levels of FVIIa in septic patients. Similar results have been demonstrated for Factor X (FX) and thrombin. In addition, several studies have been conducted to investigate the role of heparin in treating sepsis and have yielded promising results, however, the exact mechanisms remain elusive, and the clinical implications of crosstalk between coagulation pathways and sepsis are yet to be determined. Furthermore, the role of vitamin-K antagonist in sepsis has not been investigated. OBJECTIVETo assess the effects of pre-existing anticoagulation with warfarin on the clinical course of septic patient. METHODSThis was a retrospective observational study undertaken in a community-based teaching hospital. Patients who were admitted with a primary diagnosis of sepsis from January 01 to June 30, 2012 were included in the study. The clinical characteristics between patient groups without and with prior anticoagulation were compared and analyzed. The primary outcomes include the severity of sepsis, length of hospitalization, and mortality rate during hospitalization. RESULTSA total of 134 septic patients were included in the study. Among them, 105 patients were not anticoagulated, while 29 patients were anticoagulated, prior to admission (mean age: 76.0 + 1.2 vs. 77.5 + 2.6, p = 0.603). All of the patients with anticoagulation had been taking warfarin due to either pre-existing atrial fibrillation (79.3%) or deep vein thrombosis/pulmonary embolism (20.7%). There were significant differences in International Normalized Ratio (INR) of prothrombin time between groups without and with anticoagulation at the time of admission (1.28 + 0.04 vs. 4.59 + 0.83, p < 0.001). Septic patients who did not take warfarin prior to admission presented with higher Sepsis Indices (0.93 + 0.03 vs. 0.82 + 0.05, p < 0.05), resulting in longer hospitalizations (11.60 + 1.02 vs. 8.40 + 0.70, p < 0.001). The overall all-cause mortality rates during the hospitalization between patients without anticoagulation and those with anticoagulation were 23% vs. 14%, respectively. CONCLUSIONTo our knowledge, this is the first study to demonstrate that septic patients with prior anticoagulation by a vitamin-K antagonist presented with less severity of sepsis, reduced length of hospital stay, and decreased all-cause mortality during hospitalization as compared with those without anticoagulation. In our study, prior administration of anticoagulation with warfarin may have had significant clinical implications in septic patients. This warrants further prospective studies. DisclosuresNo relevant conflicts of interest to declare.

Algorithm for anticoagulation management in geriatric hip fracture patients—Surgeons save Blood

During the past decades, the number of hip fractures has been increasing steadily. Perioperative thromboprophylaxis has become a routine aspect in the care of geriatric hip fracture patients. In addition, a large proportion of these patients are already anticoagulated because of internistic comorbidities before they sustained the hip fracture. Although the management of preexisting anticoagulation in both orthopedic elective and emergency procedures is well reported, proximal femoral fractures are classified as "acute" and therefore represent neither of these two categories. In this study, we review the different options of handling preexisting anticoagulation and antiaggregation as well as perioperative thromboprophylaxis. The Innsbruck Algorithm for the management of anticoagulation in geriatric hip fracture patients suggests how perioperative bleeding risk can be minimized, while still addressing the underlying disease.

Adverse Events Associated With Mohs Micrographic Surgery

Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. To quantify adverse events associated with MMS and detect differences relevant to safety. Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.