Preoperative Acetylsalicylic Acid Research Articles

Albumin Infusion and Blood Loss After Cardiac Surgery

BackgroundIn the recent ALBICS (ALBumin In Cardiac Surgery) trial, 4% albumin used for cardiopulmonary bypass priming and volume replacement increased perioperative bleeding compared with Ringer acetate. In the present exploratory study, albumin-related bleeding was further characterized. MethodsRinger acetate and 4% albumin were compared in a randomized, double-blinded fashion in 1386 on-pump adult cardiac surgery patients. The study end points for bleeding were the Universal Definition of Perioperative Bleeding (UDPB) class and its components. ResultsThe UDPB bleeding grades were higher in the albumin group than the Ringer group: “insignificant” (albumin vs Ringer: 47.5% vs 62.9%), “mild” (12.7% vs 8.9%), “moderate” (28.7% vs 24.4%), “severe” (10.2% vs 3.2%), and “massive” (0.9% vs. 0.6%; P < .001). Patients in the albumin group received red blood cells (45.2% vs 31.5%; odds ratio [OR], 1.80; 95% CI, 1.44-2.24; P < .001), platelets (33.3% vs 21.8%; OR, 1.79; 95% CI, 1.41-2.28; P < .001), and fibrinogen (5.6% vs 2.6%; OR, 2.24; 95% CI, 1.27-3.95; P < .05), and underwent resternotomy (5.3% vs 1.9%; OR, 2.95; 95% CI, 1.55-5.60, P < .001) more often than patients in the Ringer group. The strongest predictors of bleeding were albumin group allocation (OR, 2.18; 95% CI, 1.74-2.74) and complex (OR, 2.61; 95% CI, 2.02-3.37) and urgent surgery (OR, 1.63; 95% CI, 1.26-2.13). In interaction analysis, the effect of albumin on the risk of bleeding was stronger in patients on preoperative acetylsalicylic acid. ConclusionsPerioperative administration of albumin, compared with Ringer’s acetate, resulted in increased blood loss and higher UDBP class. The magnitude of this effect was similar to the complexity and urgency of the surgery.

Impact of acetylsalicylic acid (ASA) on postoperative hemorrhage in spinal lumbar surgery: Should preoperative ASA be discontinued for elective surgery?

ObjectiveThe application of acetylsalicylic acid (ASA) represents high evidence in the aging society due to primary and secondary prevention in cardiovascular disease and stroke. However, this presents a challenge for neurosurgeons in terms of preoperative and postoperative management of care. This study aimed to analyze the risk of bleeding by applying ASA before lumbar spinal surgery. MethodsRetrospective analysis of medical records of 3051 patients was performed from 2008 to 2018 who underwent lumbar surgery at our institution. The risk of postoperative hemorrhage was compared in patients treated with ASA versus patients without ASA treatment. Additionally, the relationship between discontinuation of ASA preoperatively (≥7 days) or no previous history of ASA versus continuation with ASA (<7 days) on postoperative hemorrhage was analyzed. ResultsPostoperative hemorrhagic were observed in 2.1% (n = 63) of all lumbar operations. In 421 patients, the effect of ASA (<7 days) was still persistent at the time of surgery (ASA impact group). Of these, 12 (2.85%) patients had a hemorrhage. No significant differences were found in comparison to the No ASA impact group (p = 0.272). Sex (p = 0.003), hypertension (p = 0.015), recurrent surgery (p = 0.001) and use of hemostatic agents (p = 0.023) had a significant impact on postoperative hemorrhage. ConclusionThe continuation of ASA medication is not associated with increased risk of postoperative hemorrhage after spinal surgery. However, sex, hypertension, recurrent surgery and the use of hemostatic agents under continued ASA treatment were found to be associated with an increased risk of hemorrhage.

Coronary artery bypass graft surgery in patients on ticagrelor therapy is not associated with adverse perioperative outcomes

BackgroundManagement of patients treated with Ticagrelor is challenging, as stopping Ticagrelor prior to coronary bypass graft surgery (CABG) may increase the risk of acute stent thrombosis. The aim of the study was to compare bleeding complications in patients treated with ticagrelor combined with acetylsalicylic acid (ASA) versus ASA alone until 1 day before surgery.MethodsBleeding complications, defined as the composite of red blood cell transfusion ≥1000 ml, chest drainage ≥2000 ml, and bleeding requiring surgical re-exploration, were compared in 161 patients, with 101 on preoperative acetylsalicylic acid (ASA) alone (group A) and 65 on ticagrelor + ASA (group B).ResultsThere were no differences in bleeding complications between the two groups (26% vs. 27% in group A and B, respectively), with similar chest drainage in the first 24 h (569 ± 393 ml and 649 ± 427 ml, respectively).ConclusionsContinuing ticagrelor until coronary artery bypass surgery was not associated with increased bleeding complications, suggesting that continued management with ticagrelor until surgery may be safe.

Effect of Acetylsalicylic Acid Dose and Time Discontinued Preoperatively on Outcomes After Total Knee and Hip Arthroplasty.

The purpose of this study was to determine if acetylsalicylic acid (ASA) dose or time discontinued preoperatively affected surgical outcomes in total joint arthroplasty (TJA). The authors hypothesized that ASA worsens surgical outcomes in patients receiving higher doses and in those who discontinue ASA closer to the operative date. A total of 2853 TJAs (1802 primary total knee arthroplasties and 1051 total hip arthroplasties) performed at a tertiary medical center were reviewed. Postoperative outcomes of patients receiving ASA prior to TJA, dosing of ASA (81 mg or 325 mg) preoperatively and postoperatively, and the time of preoperative discontinuation (no ASA, <4 days, <7 days, and 7 or more days) were compared. Preoperative ASA was a risk factor for readmission (odds ratio [OR], 1.86; P<.001) and 90-day postoperative events (OR, 1.26; P=.004). Among patients receiving ASA, the dose was not a risk factor for any of the studied outcomes. Discontinuing ASA 7 or more days prior to TJA was protective for hematomas (OR, 0.64; P=.038), emergency department visits (OR, 0.79; P=.006), readmission (OR, 0.65; P<.001), and 90-day postoperative events (OR, 0.72; P<.001). These outcomes had a time effect: the risk was greater for those who discontinued therapy closer to the operative date. Patients who discontinued ASA 7 or more days prior to TJA had a lower incidence of hematomas, emergency department visits, readmissions, and 90-day postoperative events. This study's findings support discontinuing ASA at least 7 days prior to TJA. [Orthopedics. 2019; 42(5):286-293].

Stopping versus continuing acetylsalicylic acid before coronary artery bypass surgery: A systematic review and meta-analysis of 14 randomized controlled trials with 4499 patients.

This study aimed to evaluate the efficacy and safety of continuing versus stopping aspirin [acetylsalicylic acid (ASA)] preoperatively in patients undergoing coronary artery bypass graft surgery. MEDLINE, EMBASE, CENTRAL/Cochrane Controlled Trials Register (CCTR), ClinicalTrials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino Americana em Ciências da Saúde (LILACS), Google Scholar and reference lists of relevant articles were searched for randomized controlled trials that reported efficacy outcomes of myocardial infarction and mortality, and safety outcomes of blood loss, packed red blood cell transfusion and surgical re-exploration were compared between groups. Fourteen studies fulfilled our eligibility criteria and included a total of 4499 patients (2329 for 'continuing ASA' and 2170 for 'stopping ASA'). In the pooled analysis, continuing aspirin therapy did not reduce the risk of myocardial infarction [risk ratio 0.834, 95% confidence interval (CI) 0.688-1.010; P = 0.063] or operative mortality (risk ratio 1.384, 95% CI 0.727-2.636; P = 0.323). Preoperative ASA increased postoperative chest tube drainage (mean difference 143 ml, 95% CI 39-248 ml; P = 0.007) and packed red blood cell transfusion (mean difference 142 ml, 95% CI 55-228; P = 0.001) but did not increase the risk of surgical re-exploration (risk ratio 1.316, 95% CI 0.910-1.905; P = 0.145). This meta-analysis found no statistically significant difference regarding the risk of operative mortality and myocardial infarction between the 'continuing ASA' and 'stopping ASA' strategies. On the other hand, the mean volume of blood loss and packed red blood cell transfusion was higher in the 'continuing ASA' group, but this finding did not translate into higher risk of reoperation for bleeding.

Preoperative Ticagrelor administration leads to a higher risk of bleeding during and after coronary bypass surgery in a case-matched analysis.

To evaluate the effect of Ticagrelor on intra- and postoperative bleeding complications in patients undergoing coronary bypass surgery. For this study, patients who underwent on-pump or off-pump coronary bypass surgery with preoperative acetylsalicylic acid (ASA) and Ticagrelor administration, between January 2014 and December 2014, were included. In the matched control group, continued dual antiplatelet therapy (DAPT) consisted of Clopidogrel and ASA. A total of 28 consecutive patients (24 males; 73 ± 6.6 years) with preoperative Ticagrelor intake underwent elective (n = 22), urgent (n = 2) or emergency (n = 4) cardiac bypass surgery. The postoperative blood loss, red blood cell units given and intra- and postoperative bleeding complications were documented. To evaluate the effect of Ticagrelor treatment on bleeding during and after coronary bypass surgery in a non-randomized study, we used a case-matched analysis. Baseline parameters showed no important differences between the study group and the control group regarding the matching variables, left ventricular function, preoperative clinical status and risk stratification. The preoperative laboratory analysis showed no important differences regarding coagulation and blood cell count parameters. Overall blood loss was significantly higher in the study group with a mean loss of 1028.8 ± 735.5 ml (P = 0.0002). Accordingly, units of red blood cells administered were also significantly higher in the study group (P = 0.0002). In the Ticagrelor group, there were six rethoracotomies due to postoperative bleeding with a blood loss of more than 1200 ml in the first 3 h. With no rethoracotomies in the Clopidogrel group, this also showed statistical significance for the postoperative course (P = 0.02). There were no differences found regarding ICU stay and ventilation time. Comparing the mean hospital stay, the study group presented a significantly longer stay than the control group (P = 0.001). Recent studies about bleeding complications in patients with Ticagrelor intake undergoing CABG in a real-life scenario presented inconsistent data. We were able to show in a case-matched analysis that Ticagrelor administration leads to significantly higher blood loss, more red blood cell units transfused and a higher rate of rethoracotomies. The data also present a longer hospital stay to the disadvantage of the study group. Consequently, Ticagrelor intake before CABG procedures should be avoided or at least discontinued 3 days before cardiac surgery.

Effects of Perioperative Acetyl Salicylic Acid on Clinical Outcomes in Patients Undergoing Craniotomy for Brain Tumor

To evaluate the safety of continuing acetyl salicylic acid (ASA) in patients undergoing brain tumor resection. Many patients are on antiplatelet agents that are withheld before elective neurosurgical procedures to reduce bleeding risk. Cessation of ASA in patients with cardiovascular disease is associated with a known increased risk of thrombotic events, especially in patients with coronary stents. The medical records of patients who underwent surgical resection of a brain tumor at the University of Florida from 2010 to 2014 were evaluated. The patients were separated into groups based on preoperative ASA use and whether or not it was stopped before surgery. Patients were evaluated for thrombotic complications, postoperative hemorrhage, estimated blood loss, length of hospital stay, and discharge disposition. Of the 452 patients analyzed, 368 patients were not on chronic ASA therapy, 55 patients had their ASA discontinued before surgery, and 28 patients were continued on ASA perioperatively. The patients on preoperative ASA were comparable on all collected demographic variables. There were no statistical differences detected between the groups for outcomes including bleeding complications, need for reoperation, or thrombotic complications. In this analysis, perioperative low dose ASA use was not associated with increased risk of perioperative complications.

A case-cohort study of postoperative myocardial infarction: Impact of anemia and cardioprotective medications

Postoperative myocardial infarction (poMI) is a serious and costly complication. Multiple risk factors for poMI are known, but the effect of anemia and cardioprotective medications have not been defined in real-world surgical practice. Patients undergoing inpatient elective surgery were assessed at 17 hospitals from 2008 to 2011 for the occurrence of poMI (American Heart Association definition). Non-MI control patients were chosen randomly on the basis of case type. Descriptive, univariable, and multivariable statistical analysis were performed for primary outcomes of poMI and death at 30days. Compared with controls (N=304), patients with poMI (N=222) were older (72±11 vs 60±17years, P<.0001), had a lesser preoperative hematocrit (37±6 vs 39±5, P<.0001), more often were smokers, had a preoperative T-wave abnormality (21% vs 9%, P<.0001), and had a preoperative stress test with a fixed deficit (26% vs 3%; P<.001). Preoperative factors associated with poMI included peripheral vascular disease (odds ratio 2.6; 95% confidence interval 1.3-5.3), tobacco use (1.7; 1.01-2.9), history of percutaneous coronary angioplasty (2.8; 1.6-5.0), and age (1.05; 1.03-1.07), whereas hematocrit >35 (0.51; 0.32-0.82) and preoperative acetylsalicylic acid, ie, aspirin (0.59; 0.4-0.97) were protective. Preoperative β-blockade, statin, and use of angiotensin-converting enzyme inhibitors were not associated with lesser rates of poMI. Non-MI complication rates were 23-fold greater in the poMI group compared with the control group (P<.0001). Mortality with poMI within 30days was 11% compared with 0.3% in non-MI control patients (P<.0001). In patients with poMI, factors independently associated with death included use of epidurals (3.5; 1.07-11.4) and bleeding (4.2; 1.1-16), whereas preoperative use of aspirin (0.29; 0.1-0.88), and postoperative β-blockade (0.18; 0.05-0.63) were protective. Cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass grafting after poMI was performed in 34% of those alive and 20% of those who died (P=.16). In the current era, poMI patients have a markedly increased risk of death. This risk is decreased with preoperative use of acetylsalicylic acid and post MI β-blockade. Further study is warranted to explore the role of anemia and cardiac interventions after poMI.

Usefulness of Monitoring Platelet Function by Multiple Electrode Aggregometry in Primary Coronary Artery Bypass Surgery

Antiplatelet therapy commonly is used for the prevention of cardiovascular complications but increases the risk of perioperative bleeding. Multiple-electrode aggregometry (MEA) was investigated for monitoring platelet inhibition by acetylsalicylic acid (ASA) and clopidogrel in patients undergoing elective coronary artery bypass graft (CABG) surgery with regard to clinical outcome as measured by postoperative blood loss and transfusion requirements. A prospective observational study. A teaching hospital. One hundred fifty patients scheduled for elective CABG surgery were included: without antiplatelet therapy (group A, n = 50), single ASA exposure (group B, n = 50), and combined therapy with ASA and clopidogrel (group C, n = 50). MEA was assessed preoperatively using either collagen (COL-MEA) or ADP (ADP-MEA). Postoperative blood loss and transfusion requirements were recorded for 24 hours after surgery. Postoperative blood loss significantly increased only from combined antiplatelet therapy (group A: 572 ± 297 mL, group B: 721 ± 356 mL, group C: 865 ± 346, p < 0.01) and correlated with ADP (r(p) = -0.35, p < 0.01) and COL-MEA (r(p) = -0.23, p > 0.01). COL-MEA and ADP-MEA discriminated between preoperative ASA and clopidogrel intake (ASA: sensitivity = 86.3%, and specificity = 89.3%; clopidogrel: sensitivity = 87.5%, and specificity = 95.1%). The postoperative transfusion risk was increased in patients diagnosed for clopidogrel treatment by ADP-MEA (odds ratio = 2.92; confidence interval: 1.44-5.92; p = 0.005). MEA is a suitable method for the detection of platelet inhibition by ASA and clopidogrel in patients undergoing CABG surgery. In these patients, preoperative ADP MEA seems to indicate patients at risk for postoperative transfusion requirements.

Preoperative acetylsalicylic acid increases blood transfusions in CABG on CPB

Preoperative acetylsalicylic acid increases blood transfusions in CABG on CPB