Although many studies in the cardiothoracic literature exist about the relationship between clopidogrel and postoperative bleeding, there is scarce data in the general surgery literature. We assessed whether there are increased bleeding complications, morbidity, mortality, and resource utilization in patients who are on clopidogrel (Plavix®) within 1 week before undergoing a general surgery procedure. Fifty consecutive patient charts were retrospectively reviewed after identifying patients who had pharmacy orders for clopidogrel and who underwent a general surgery procedure between 2003 and 2007. Patients who took clopidogrel within 6 days before surgery (group I, n = 28) were compared with patients who stopped clopidogrel for 7 days or more (group II, n = 22). A larger percentage of patients who took their last dose of clopidogrel within 1 week of surgery (21.4% vs 9.5%) had significant bleeding after surgery requiring blood transfusion. However, there were no significant differences between the groups in operative or postoperative blood transfusions ( P = 0.12, 0.53), decreases in hematocrit ( P = 0.21), hospital stay ( P = 0.09), intensive care unit stay ( P = 0.41), late complications ( P = 0.45), or mortality ( P = 0.42). Although our cohort is limited in size, these results suggest that in the case of a nonelective general surgery procedure where outcomes depend on timely surgery, clopidogrel taken within 6 days before surgery should not be a reason to delay surgery. However, careful attention must be paid to meticulous hemostasis, and platelets must be readily available for transfusion in the operating room.
SummaryFailed spinal anaesthesia for left total hip arthroplasty was followed postoperatively by dense motor paralysis and sensory deficit in the right leg. The patient had received a dose of subcutaneous heparin 1 h before the spinal anaesthetic was attempted. She died of pulmonary embolism on the ninth postoperative day. At autopsy extensive haematomyelia was found in relation to the needle track. Case reportAn overweight woman of 66 years (height 163 cm weight 87 kg) presented for a left Charnley total hip replacement. She had a history of deep vein thrombosis some 10 years previously, apart from which and notwithstanding her weight, she had remained in good general health. Her only medication was fenbufen for arthritis, which she had not taken for 1 week prior to the operation and co-codamol as required for pain. The patient was frankly advised of the danger of hip surgery but was keen to proceed because her arthritis was severely disabling and her pain constant. She had been waiting for surgery for some months and had been able to lose 8 kg in weight.Pre-operative laboratory investigations showed a haemoglobin of 12.9 g.dl ÿ 1 and platelets of 170 000 × 10 9 .l ÿ 1 . The patient's clotting function was not investigated.Despite the practical difficulties caused by her weight, regional analgesia was chosen. Premedication was with midazolam 5 mg intramuscularly and low-dose heparin was prescribed (5000 i.u. calcium heparin subcutaneously twice daily) the first dose being given 1 h pre-operatively.Spinal anaesthesia was attempted in the left lateral position with a 26G needle. It was extremely difficult to palpate the bony landmarks of the back but the subarachnoid space was located at the first attempt in what was believed to be the L 3-4 interspace and free flow of cerebrospinal fluid was observed. On injection of the local anaesthetic the patient complained of intense pain, described as sharp and stabbing in nature, down the left leg. The subarachnoid injection was abandoned and the needle withdrawn. A total of 0.3 ml of heavy bupivacaine 0.5% in 12% dextrose had been injected. The situation was discussed with the patient who was now pain free and it was decided to proceed with general anaesthesia. This was induced with thiopentone 250 mg and controlled ventilation with nitrous oxide, oxygen 30% and isoflurane 0.5% was facilitated with vecuronium. A total of 12 mg of morphine was administered during surgery. The operation was uneventful and the systolic blood pressure remained in the range 110-140 mmHg throughout. The duration of surgery was 90 min.The patient complained of moderate pain at the operative site and was given a further 5 mg of morphine intravenously in the recovery unit. Her immediate postoperative progress was otherwise unremarkable. The following morning when the patient awoke she complained that her right leg was numb and weak. Neurological examination confirmed this and neurological and neurosurgical opinions were sought. ᮊ 1997 Blackwell Science LtdOn physical examination a right-sided u...
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