22 Oct 10
Posted in Anticoagulation, Antiplatelet therapy, Pre-operatie evaluation at 0:35 by Laci
By J Rabbitts, G Nuttall, M Brown, A Hanson, W Oliver, D Holmes, C Rihal, Charanjit
Anesthesiology 2008;109:596-604
The American College of Cardiology released a scientific advisory that included a recommendation to delay elective of noncardiac surgery (NCS) for 1 yr after percutaneous coronary intervention (PCI) with a drug-eluting stent (DES).
Methods
This single-center, retrospective study examined the risk for complications of NCS performed within 2 yr after DES placement and examined whether this risk changed based on the time between procedures. The primary endpoint was major adverse cardiac events (MACEs) during the hospitalization for NCS. Bleeding events were analyzed as a secondary endpoint.
Results
From April 22, 2003, to December 31, 2006, a total of 520 patients underwent NCS within 2 yr after PCI with a DES at Mayo Clinic. The majority, 84%, of the DES placed were Cypher stents. The frequency of MACE was not found to be significantly associated with the time between PCI and NCS (rate of MACEs 6.4, 5.7, 5.9, and 3.3% at 0-90, 91-180, 181-365, and 366-730 days after PCI with DES, respectively; P = 0.727 for comparison across groups). Characteristics found to be associated with MACEs in univariate analysis were advanced age (P = 0.031), emergent NCS (P = 0.006), shock at time of PCI (P = 0.035), previous history of myocardial infarction (P = 0.046), and continuation of a thienopyridine (ticlopidine or clopidogrel) into the preoperative period (P = 0.040). The rate of transfusion did not seem to be associated with antiplatelet therapy use.
Conclusions
The risk of MACEs with NCS after DES placement was not significantly associated with time from stenting to surgery, but observed rates of MACEs were lowest after 1 yr.
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14 Oct 10
Posted in Antiplatelet therapy, Coronary artery disease, Pre-operatie evaluation at 10:00 by Laci
By The Cardiac Society of Australia and New Zealand
Coronary stent thrombosis is an uncommon but clinically devastating complication of coronary artery stenting that usually results in significant myocardial infarction or death. The pathophysiology of stent thrombosis is related to non-endothelialisation of the stent struts, often due to inadequate deployment or delayed healing in the case of drug eluting stents.
Approximately 40% of reported cases have occurred in the context of non-cardiac surgery (NCS) performed in patients with coronary artery stents, in whom dual antiplatelet therapy or clopidogrel alone has been ceased.
In patients with coronary disease cessation of aspirin or clopidogrel is associated with an approximate 2-3 fold increase in subsequent death or myocardial infarction. This risk is further elevated in patients with intracoronary stent and is of added concern because the dramatic consequences of stent occlusion. There is uncertainty regarding the risks of stent thrombosis in individual patients, and in particular how to balance this risk against that of surgical complications if antiplatelet therapy is continued throughout the perioperative period.
This guideline provides consensus advice regarding the use of antiplatelet therapy in patients with intracoronary stents for whom non-cardiac invasive procedures are planned. It is designed for cardiologists, anaesthetists, surgeons and dentists preparing patients for these procedures.
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Posted in Antiplatelet therapy, Coronary artery disease, Pre-operatie evaluation at 9:55 by Laci
By S Savonitto, M D’Urbano, M Caracciolo, F Barlocco, G Mariani, M Nichelatti,
BJA 2010;104:285-291
Patients with a recently implanted coronary drug-eluting stent (DES) who need urgent surgery are at increased risk of surgical bleeding unless clopidogrel is discontinued beforehand, but clopidogrel discontinuation has been associated with a high rate of adverse events due to stent thrombosis. This pilot study tested the hypothesis that the i.v. perioperative administration of the short-acting antiplatelet agent tirofiban allows the safe withdrawal of clopidogrel without increasing the rate of surgical bleeding.
Methods
Phase II study with a Simon two-stage design.
Results
Thirty patients with a recently implanted DES [median (range) 4 (1–12) months] and high-risk characteristics for stent thrombosis underwent urgent major surgery or eye surgery. Clopidogrel was to be withdrawn 5 days before surgery, and tirofiban started 24 h later, continued until 4 h before surgery, and resumed 2 h after surgery until oral clopidogrel was resumed. The use of aspirin was decided by the surgeon. There were no cases of death, myocardial infarction, stent thrombosis, or surgical re-exploration due to bleeding during the index admission, with a risk estimate of 0–11.6% (one-tail 97.5% CI). There was one case of thrombolysis in myocardial infarction (TIMI) major and one of TIMI minor bleeding in the postoperative phase; another four patients were transfused without meeting the TIMI criteria for major or minor bleeding.
Conclusions
In patients with a recently implanted DES and high-risk characteristics for stent thrombosis needing urgent surgery, a ‘bridging strategy’ using i.v. tirofiban may allow temporary withdrawal of oral clopidogrel without increasing the risk of bleeding.
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14 Sep 10
Posted in Anesthesia, COPD, Pre-operatie evaluation at 0:05 by Laci
By T Edrich, N Sadovnikoff
Curr Opin Anaesth. 2010;2:18-24
Patients with chronic obstructive lung disease experience an increased risk of perioperative pulmonary complications. This review presents an evidence-based approach to perioperative care designed to optimize management.
Recent findings: Recent research has provided guidance regarding intraoperative and postoperative administration of oxygen and the selective use of volatile agents. The significance of preoperative malnutrition and postoperative epidural analgesia on outcomes has also been explored further. The opportunity for anesthesiologists to engage in tobacco interventions and the benefits of addressing smoking cessation have been studied.
Summary
Optimization for surgery includes preoperative treatment of reversible airway obstruction and respiratory infections, smoking cessation, and possibly nutritional interventions. Meticulous intraoperative monitoring combined with a sound understanding of pathophysiological mechanisms underlying air trapping will help clinicians strike a balance between permissive hypercapnia and adequate ventilation.
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