Risk Factors For Hemorrhagic Complications Research Articles

Risk of hemorrhagic complication associated with ventriculoperitoneal shunt placement in aneurysmal subarachnoid hemorrhage patients on dual antiplatelet therapy

The use of an intracranial stent requires dual antiplatelet therapy to avoid in-stent thrombosis. In this study, the authors sought to investigate whether the use of dual antiplatelet therapy is a risk factor for hemorrhagic complications in patients undergoing permanent ventriculoperitoneal (VP) shunt for hydrocephalus following aneurysmal subarachnoid hemorrhage (aSAH). Patients were given 325 mg acetylsalicylic acid and 600 mg clopidogrel during the coil/stent procedure, and they were maintained on dual antiplatelet therapy with acetylsalicylic acid 325 mg daily and clopidogrel 75 mg daily during hospitalization and for 6 weeks posttreatment. Patients underwent placement of VP shunt at a later time during initial hospitalization, usually between 7 and 21 days following aSAH. Postoperative CT scans obtained in each study patient were reviewed for hemorrhages related to placement of the VP shunt. A total of 206 patients were admitted to the University of Iowa Hospitals and Clinics with aSAH between July 2009 and October 2010. Thirty-seven of these patients were treated with a VP shunt for persistent hydrocephalus. Twelve patients (32%) had previously undergone stent-assisted coiling and were on dual antiplatelet therapy with acetylsalicylic acid and clopidogrel. The remaining 25 patients (68%) had undergone surgical clipping or aneurysm coiling and were not receiving antiplatelet therapy at the time of surgery. Four cases (10.8%) of new intracranial hemorrhages associated with VP shunt placement were observed. All 4 hemorrhages (33%) occurred in patients on dual antiplatelet therapy for stent-assisted coiling. No new intracranial hemorrhages were observed in patients not receiving dual antiplatelet therapy. The difference in hemorrhagic complications between the 2 groups was statistically significant (4 [33%] of 12 vs 0 of 25, p = 0.0075]). All 4 hemorrhages occurred along the tract of the ventricular catheter. Only 1 hemorrhage (1 [8.3%] of 12) was clinically significant as it resulted in occlusion of the proximal shunt catheter and required revision of the VP shunt. The patient did not suffer any permanent morbidity related to the hemorrhage. The remaining 3 hemorrhages were not clinically significant. This small clinical series suggests that placement of a VP shunt in patients on dual antiplatelet therapy may be associated with an increased, but low, rate of symptomatic intracranial hemorrhage. It appears that in patients who are poor candidates for open surgical clipping and have aneurysms amenable to stent-assisted coiling, the risk of symptomatic hemorrhage may be an acceptable trade-off for avoiding risks associated with discontinuation of antiplatelet therapy. The authors' results are preliminary, however, and require confirmation in larger studies.

Hemorrhagic complications after intravitreal ranibizumab injection for polypoidal choroidal vasculopathy

ObjectiveTo evaluate clinical features and risk factors for hemorrhagic complications in eyes with polypoidal choroidal vasculopathy (PCV) after intravitreal ranibizumab injection. DesignRetrospective case series. ParticipantsThe charts of 54 patients with PCV who had received intravitreal ranibizumab 0.5 mg. MethodsThe study was conducted as a retrospective chart review of 54 patients with PCV who had received intravitreal ranibizumab 0.5 mg. Analysis of 2 groups was based on mean PCV lesion size: < 15mm2 (n = 24); or ≥ 15mm2 (n = 32). The occurrence of fresh postoperative subretinal hemorrhage, best corrected visual acuity, systemic disease, and medication history were documented and analyzed. ResultsThe mean injection number was 3.3 ± 0.7 (range, 1 to 6), with a mean follow-up of 7.4 ± 2.8 months (range, 4 to 14 months). During the follow-up period, postoperative subretinal hemorrhage was observed in 5 (8.9%) of 56 eyes. Occurrence of postoperative hemorrhage was significantly increased in the group with large PCV size (p = 0.01). Pars plana vitrectomy was performed for postoperative bleeding that resulted in vitreous hemorrhage in 1 eye (1.8%). Various systemic diseases and medication with an anticoagulant had no correlation with occurrence of hemorrhagic complications. ConclusionsSubretinal hemorrhage after ranibizumab injection can occur in patients with PCV. When considering ranibizumab injection for treatment of a large PCV lesion, the risk for hemorrhagic complications should be considered.

RISK FACTORS FOR THE DEVELOPMENT OF HEMORRHAGIC SYNDROME IN NEONATAL PERIOD

The problem of hemostasis disturbances in neonatology gains currency due to its physiological instability aggravated by various pathologic processes. Based on literary data, the article systematizes the causes that lead to the disturbance of hemostasis functioning in the neonatal period and characterizes the risk factors for hemorrhagic complications from the neonate and the mother. It has been shown that the state of microcircular hemostasis in the neonates demands its detailed investigation, as the received knowledge about the functioning of primary hemostasis will make it possible to decide a lot of important issues that relate to the disturbance correction in hemorrhagic syndrome in the neonates.

Predictors of Hemorrhage After Laparoscopic Partial Nephrectomy

To identify risk factors associated with hemorrhage during laparoscopic partial nephrectomy (LPN), and to determine the impact of hemorrhage on hospital course. We retrospectively analyzed prospective data from 335 LPNs to identify clinicopathologic factors associated with hemorrhagic complications (blood loss requiring ≥ 1 U transfusion) and extended length of hospitalization (≥ 3 days). We excluded patients with a coagulopathy or perioperative vascular injuries. We identified 23 patients (7%) undergoing LPN with hemorrhagic complications (group 1 and 312 patients (93%) without complications (group 2). Mean age was 64.1 ± 14.4 vs 57.6 ± 12.7(P = .006), American Society of Anesthesiologists (ASA) score ≥ 3 seen in 61% vs 37% (P = .02), mean tumor size (cm) was 2.90 ± 2.02 vs 2.59 ± 1.15 (P = .93), mean total operative time (min) was 250.1 ± 116.1 vs 191.8 ± 69.2 (P = 0.006), and mean hospital stay (days) was 4.7 ± 3.4 vs 3.1 ± 3.0 (P = .0002), for groups 1 and 2, respectively. Hypertension, diabetes mellitus, chronic renal insufficiency, obesity, smoking, and coronary artery disease-congestive heart failure were present in group 1 vs group 2: 39.1% vs 31.4% (P = .4), 17.4% vs 8% (P = .12), 8.7% vs 1.9% (P = .09), 4.3% vs 3.5% (P = .57), 17.4% vs 5.4% (P = .04), and 8.7% vs 2.2% (P = .11), respectively. On multivariate analysis, smoking (P < .0437) and ASA score ≥ 3 (P < .0233) were associated with hemorrhagic complications. Hemorrhagic complications were 3.5 times more likely in smokers than nonsmokers (95% confidence interval, 1.0-11.7), and 2.9 times more likely with an ASA class ≥ 3. Only age (P < .0002) and operative time (P < .0001) were associated with longer hospitalization. High ASA scores and smoking are risk factors for hemorrhagic complications during LPN. Hemorrhagic complications did not significantly affect hospitalization length.

W1789 Risk Factors for Hemorrhagic Complications After Radiofrequency Ablation Therapy for Liver Tumors

A S L D A b st ra ct s insufficiency in 2 and liver abscess in 3 patients). A post-embolization syndrome was seen in 14%. None of the patients developed liver failure after TACE. Our study shows that TACE is an efficacious and safe therapeutic modality for HCC patients unsuitable for surgical therapy. Tumor stage, degree of liver disease, response to TACE and patients' age were independent risk factors for patient survival.

Warfarin Monitoring Woes: A Glimmer of Hope with Pharmacogenomics

Evidence-based clinical practice guidelines recommend the use of warfarin for stroke prevention in most patients with atrial fibrillation (AF) who do not have risk factors for hemorrhagic complications, or other contraindications, irrespective of age. The past couple of years have seen an increased awareness and scrutiny addressing the dilemma of warfarin prescribing with particular emphasis on risk factors that increase the propensity for overanticoagulation and bleeding. This coupled with some promising news of personalized medicine using pharmacogenomics for warfarin dosing is the focus of this commentary.

Hemorrhagic Complications from Glaucoma Surgery in Patients on Anticoagulation Therapy or Antiplatelet Therapy

To determine the incidence of and risk factors for hemorrhagic complications in patients on anticoagulation (ACT) or antiplatelet therapy (APT) having glaucoma surgery. Retrospective case-control study. Medical records of patients who had glaucoma surgery between July 1, 1998 and March 31, 2005 were reviewed. Patients who either used ACT/APT continuously throughout the perioperative period or discontinued its use prior to surgery were compared to case-matched control patients who were not on such therapies. Patients on ACT/APT who experienced postoperative hemorrhagic complications were compared to those who did not. Outcome measures included hemorrhagic complications and thromboembolic events. Three hundred and forty-seven patients (eyes) who were on ACT or APT prior to glaucoma surgery had a higher rate of hemorrhagic complications than 347 control patients (10.1% vs 3.7%, respectively, P = .002). Patients on ACT had a higher rate of hemorrhagic complications than patients on APT (22.9% vs 8.0%, respectively, P = .003). Patients who continued ACT during glaucoma surgery had the highest rate of hemorrhagic complications (31.8%) when compared to patients who discontinued ACT prior to surgery or patients who used APT alone (P = .001). Hemorrhagic complications following glaucoma surgery were more frequently associated with preoperative ACT, arrhythmia, and higher preoperative and postoperative intraocular pressures (IOP). Chronic ACT/APT was associated with a statistically significant increase in the rate of hemorrhagic complications, and perioperative ACT and a high preoperative IOP are potential risk factors for hemorrhagic complications in patients undergoing glaucoma surgery.

HEMORRHAGIC COMPLICATIONS AFTER PHOTODYNAMIC THERAPY FOR POLYPOIDAL CHOROIDAL VASCULOPATHY

To evaluate the clinical features and risk factors of hemorrhagic complications in eyes with polypoidal choroidal vasculopathy (PCV) after photodynamic therapy (PDT). We retrospectively reviewed data for 91 consecutive eyes of 85 patients who underwent PDT for the treatment of PCV. The diagnosis of PCV was based on indocyanine green angiographic findings, showing a branching vascular network terminating in polypoidal swelling. The greatest linear dimension included all polypoidal lesions, leaking vascular network, and type 2 choroidal neovascularization. During the follow-up period after PDT, postoperative subretinal hemorrhage was seen in 28 (30.8%) of 91 eyes. In 22 (78.6%) of these 28 eyes, subretinal hemorrhage was absorbed without treatment. In 6 eyes (21.4%), however, bleeding resulted in vitreous hemorrhage, and 2 eyes underwent pars plana vitrectomy. Although visual acuity was maintained or increased in 18 (81.8%) of 22 eyes with subretinal hemorrhage alone, it decreased significantly in 3 (50.0%) of 6 eyes with postoperative vitreous hemorrhage. Various systemic diseases and medication with an anticoagulant had no correlation with these hemorrhagic complications. Laser irradiation spot size for PDT was significantly larger in eyes with postoperative vitreous hemorrhage (P = 0.017) than in those without. Subretinal hemorrhage after PDT can be a common complication in patients with PCV and may have a minor effect on visual outcome. However, postoperative hemorrhage is occasionally so massive that it leads to vitreous hemorrhage and poor visual prognosis. When considering PDT for eyes with a large PCV lesion, ophthalmologists should be aware of the risk of serious hemorrhagic complications.

Low-dose aspirin before spinal surgery: results of a survey among neurosurgeons in Germany

The main problem faced by the increasing numbers of patients presenting for spinal surgery are receiving concurrent medication with low-dose aspirin, leading to dysfunctional circulating platelets. The contribution of low-dose aspirin to increased peri-operative risk of bleeding and blood loss is a contentious issue with conflicting published results from different surgical groups. Data from neurosurgical spine patients is sparse, but aspirin has been identified as an important risk factor in the development of post-operative hematoma following intracranial surgery. We surveyed the opinions and working practices of the neurosurgical facilities performing spinal operations in Germany regarding patients who present for elective spinal surgery. Identical questionnaires were sent to 210 neurosurgical facilities and proffered five main questions: (1) the adherence of any policy of stopping aspirin pre-operatively, (2) the personal risk assessment for patients with spinal surgery under low-dose aspirin medication, (3) the preferred method of treatment for excessive bleeding in this context, (4) personal knowledge of hemorrhagic complications in this group of patients, and (5) the characteristics of the neurosurgical units concerned. There were 145 (69.1%) responses of which 142 (67.6%) were valid. Of the respondents, 114 (80.3%) had a (written) departmental policy for the discontinuation of pre-operative aspirin treatment, 28 (19.7%) were unaware of such a policy. The mean time suggested for discontinuation of aspirin pre-operatively was 6.9 days (range: 0-21 days), with seven respondents who perform the operations despite the ongoing aspirin medication. Ninety-four respondents (66.2%) considered that patients taking low-dose aspirin were at increased risk for excessive peri-operative hemorrhage or were indetermined (8.6%), and 73 (51.4%) reported having personal experience of such problems. Ninety-two respondents (65.5%) would use special medical therapy, preferably Desmopressin alone or in combination with other blood products or prohemostatic agents (46.1%), if hemorrhagic complications developed intra- or post-operatively. The average number of spinal operations per year in each service was 607.9 (range: 40-1,500). Despite the existence of distinct departmental policies concerning the discontinuation of low-dose aspirin pre-operatively in the majority of neurosurgical facilities performing spinal operations, there is a wide range of the moment of this interruption with an average of 7 days. Two-thirds of the respondents felt that aspirin was a risk factor for hemorrhagic complications associated with spinal procedures, and more than half of the interviewees reported having personal experience of such problems. Finally, various medicamentous methods of counteracting aspirin-induced platelet dysfunction and excessive bleeding in this context are elicited, discussed and evaluated.

Clinical importance of microbleeds in patients receiving IV thrombolysis

Cerebral microbleeds (MBs) detected on gradient echo (GRE) imaging may be a risk factor for hemorrhagic complications in patients with stroke treated with IV tissue plasminogen activator (tPA). The authors prospectively evaluated patients with acute ischemic stroke treated with IV tPA between 3 and 6 hours of symptom onset. MRI scans, including GRE imaging, were performed prior to tPA treatment, 3 to 6 hours after treatment and at day 30. The authors compared the frequency of hemorrhagic complications after thrombolysis in patients with and without MBs on their baseline GRE imaging. Seventy consecutive patients (mean age, 71 +/- 29 years; 31 men, 39 women) were included. MBs were identified in 11 patients (15.7%) on baseline GRE imaging. There was no significant difference in the frequency of either symptomatic or asymptomatic hemorrhagic complications after thrombolysis between patients with and without MBs at baseline. None of the 11 patients with MBs (0%) at baseline had a symptomatic intracerebral hemorrhage compared with 7 of 59 patients who did not have baseline MBs (11.9%). In addition, no patients with baseline MBs had asymptomatic hemorrhagic transformation observed at the site of any pre-treatment MB. The presence of cerebral microbleeds on gradient echo imaging does not appear to substantially increase the risk of either symptomatic or asymptomatic brain hemorrhage following IV tissue plasminogen activator administered between 3 and 6 hours after stroke onset.

Long‐term low‐dose warfarin use is effective in the prevention of recurrent venous thromboembolism: no

Long‐term low‐dose warfarin use is effective in the prevention of recurrent venous thromboembolism: no

Hemorrhagic complications of oculoplastic surgery.

To determine the incidence and risk factors of hemorrhagic complications associated with selected oculoplastic procedures. A prospective study was performed to document the severity of intraoperative hemorrhage and postoperative bruising in patients undergoing oculoplastic procedures. The use of anticoagulant or platelet-inhibiting medications, systemic medical conditions, patient age, patient sex, and type of procedure were examined to identify risk factors for hemorrhagic complications. Troublesome intraoperative bleeding prolonged surgery in 9.2% of cases. Severe bleeding with the potential to affect surgical outcome was encountered in 0.4% of procedures. There was little correlation between severity of bleeding and degree of postoperative bruising. Male sex, a history of heart disease, or age >60 years imparted a slightly greater risk of intraoperative bleeding. Age >60 years, hypertension, or recent cessation of aspirin may increase the risk of postoperative bruising. A history of previous stroke increased the risk of postoperative bleeding. There was no statistical difference in the incidence of hemorrhagic complications among patients currently treated with antiplatelet/anticoagulant agents, those who had stopped these medications before surgery, and those who were not treated with these agents. No patient had permanent sequelae related to hemorrhage. Two patients had postoperative systemic complications possibly attributable to withholding anticoagulant/antiplatelet medications in preparation for surgery. Although serious hemorrhagic complications may be associated with oculoplastic procedures, the incidence of these complications is low. The decision to withhold antiplatelet or anticoagulant medications before surgery should be individualized. Selected procedures can be safely performed without stopping these agents.

Prevalence and quality of warfarin use for patients with atrial fibrillation in the long-term care setting.

Evidence-based clinical practice guidelines recommend the use of warfarin sodium for stroke prevention in most patients with atrial fibrillation (AF) who do not have risk factors for hemorrhagic complications, irrespective of age. The medical records of all residents of a convenience sample of long-term care facilities in Connecticut (n = 21) were reviewed. The percentages of all patients with AF (AF patients) and ideal candidates for warfarin therapy (ie, AF patients with no risk factors for hemorrhage) who received warfarin were determined; for patients receiving warfarin, the percentage of days spent in the therapeutic range of international normalized ratio (INR) values (2.0-3.0) was also assessed. The relationship between receipt of warfarin and the presence of stroke and bleeding risk factors was assessed in multivariate models. Atrial fibrillation was present in 429 (17%) of the 2587 long-term care residents. Overall, 42% of AF patients were receiving warfarin. However, only 44 (53%) of 83 ideal candidates were receiving this therapy. In residents who received warfarin therapy, the therapeutic range of INR values was maintained only 51% of the time. The odds of receiving warfarin in the study sample decreased with increasing number of risk factors for bleeding and increased (nonsignificant trend) with increasing number of stroke risk factors present. Atrial fibrillation is very common among residents of long-term care facilities. Even among apparently ideal candidates, warfarin therapy is underused for stroke prevention in patients with AF. Prescribing decisions and monitoring related to warfarin therapy in the long-term care setting warrant improvement.

Increasing age is a major risk factor for hemorrhagic complications after pulmonary embolism thrombolysis

We reviewed our database of 312 patients with pulmonary embolism who received thrombolysis in five clinical trials. At baseline, none had a history of stroke, internal bleeding within 6 months, surgery within 10 days, or occult blood in stool. Sixty-six major bleeding episodes occurred within 72 hours of administering thrombolysis in 61 (20%) patients: bleeding at the catheterization site (34 cases), gross hematuria (9), intracranial hemorrhage (5), and 18 other bleeding episodes that led to at least a 10% hematocrit decrease. Patients with a major bleeding complication were on average older than patients with no hemorrhagic complication (mean age 62.9 ± 1.9 years vs 56.2 ± 1.1 years; p = 0.005). In an adjusted analysis, there was a fourfold increased risk of bleeding among patients older than 70 years compared with patients younger than 50 years (relative risk [RR] 3.9; 95% confidence interval [CI] 1.7 to 8.9). By using age as a continuous variable, we found a 4% (RR 1.04; 95% CI 1.02 to 1.06) increase in risk of bleeding for each incremental year of age. In addition, patients with higher body mass index had an increased risk of bleeding. Patients who had undergone catheterization had a five times greater risk of bleeding (RR 5.2; 95% CI 1.5 to 17.8). In summary, increasing age, larger body mass index, and catheterization predisposed to bleeding complications after pulmonary embolism thrombolysis. (Am Heart J 1997;134:69-72.)

Extracorporeal Lung Assist with Heparin-Coated Systems

Extracorporeal lung assist (ELA) has been recommended for the treatment of ARDS if conventional therapy fails. However, the need for nearly complete anticoagulation is a major risk factor for hemorrhagic complications. We describe our experience with 13 ARDS patients treated with ELA using heparin-coated systems (Carmeda). Maintaining partial thromboplastin time and activated clotting time within or close to the normal range, even major surgery (20 thoracotomies and 2 laparotomies) could be performed without undue bleeding complications related to anticoagulation during extracorporeal support. Eight of the 13 patients survived. The use of heparin-coated systems allows prolonged ELA with nearly physiological coagulation function, permitting major surgical intervention. It enhances the safety margin of extracorporeal gas exchange and may ultimately extend its indications.

Effect of Serum Total Cholesterol on Hemorrhagic Complications following Thrombolytic Therapy for Acute Myocardial Infarction

Despite the well-known and widely publicized adverse effects of hypercholesterolemia on the cardiovascular system, cholesterol is a vital component of cellular membranes, maintaining vascular integrity and normal platelet activatability. To test the hypothesis that a low serum total cholesterol concentration increases bleeding risk following thrombolytic therapy, a comparison of in-hospital hemorrhagic events was made between 132 patients with myocardial infarction divided into three distinct groups. Group 1 patients (n = 44) had an admitting serum total cholesterol of less than 200 mg/dl, while group 2 (n = 57) and group 3 (n = 31) patients had cholesterol levels of 200-249 and greater than or equal to 250 mg/dl, respectively. There were no significant differences between groups in either minor hemorrhagic events (p = 0.85), major hemorrhagic events (p = 0.73) or transfusion requirements (p = 0.45). In addition, the primary sites of bleeding did not differ. Over the 2-year study period, a total of four intracerebral events were identified. As with minor and other major hemorrhagic events, an association with serum total cholesterol and intracerebral hemorrhage was not observed (p = 0.29). However, advanced age (greater than 65 years; p = 0.04) and a total dose of recombinant tissue-type plasminogen activator in excess of 1.5 mg/kg body weight (p less than 0.001) were identified by multivariate analysis as risk factors for intracerebral hemorrhage. Thus, although cholesterol is vital for maintaining vascular integrity and normal hemostasis, relatively low serum levels are not a risk factor for hemorrhagic complications following thrombolytic therapy.

Experience with the use of tPA in the treatment of acute myocardial infarction

Early experience with the use of tissue plasminogen activator (tPA) in acute myocardial infarction is reviewed, including comparisons with other thrombolytic agents, a summary of hemorrhagic complications associated with its use, and the rationale for adjunctive therapeutic strategies. The use of tPA has been associated with improvement in left ventricular function, a lower mortality, and a decrease in congestive heart failure signs and symptoms. A protocol for evaluation of patients with possible myocardial infarction for thrombolytic therapy is presented. Consideration must be given to other possible diagnoses, and the ECG must be evaluated carefully to ensure that appropriate criteria are met. Risk factors for hemorrhagic complications include recent trauma, surgery, gastrointestinal and genitourinary bleeding, stroke, and focal neurologic findings. Greater benefit of therapy is expected in patients with larger infarcts who have more marked ST segment changes or evidence of hemodynamic compromise, especially when they are treated early after the onset of symptoms (within the first several hours). Adjunctive measures that can be considered in the emergency department include prophylactic lidocaine, IV nitroglycerin, beta blockade, aspirin, volume replacement and monitoring for dysrhythmias, bleeding, and recurrent ischemia. A comprehensive understanding of these rapidly evolving concepts will assist the emergency physician in the evaluation and management of patients with acute myocardial infarction.