Antiplatelet and Anticoagulant Medications Significantly Increase the Risk of Postoperative Hematoma: Review of over 4500 Thyroid and Parathyroid Procedures

Abstract

Purpose Antiplatelet and/or anticoagulant medication use is common. Abstinence a week before surgery may still result in altered hemostasis. The study aim was to report on perioperative antiplatelet and anticoagulant use in thyroidectomy and parathyroidectomy patients, and to determine the association with postoperative hematoma (POH) rates. Methods Retrospective review of a prospective endocrine surgery database was performed. Procedure extent was defined as unilateral, bilateral, or extensive. Antiplatelets were categorized as none, 325 mg aspirin (ASA), <325 mg ASA, clopidogrel, or other. Anticoagulants were categorized as none, oral, or injectable. Results A total of 4514 patients were identified. POH developed in 22 patients (0.5 %). Rates were similar between age, gender, and reoperative status. POH were seven times more common after thyroidectomy (0.8 vs. 0.1 %, p < 0.01). Unilateral procedures had lower POH rates than bilateral or extensive (0.1 vs. 0.9 vs. 0.8 %, p < 0.01). POH rates in patients receiving 325 mg ASA (0.8 %) or clopidogrel (2.2 %) were much higher than patients not receiving antiplatelets (0.5 %) or receiving <325 mg ASA (0.1 %, p = 0.04). Oral anticoagulants (2.2 %) and injectable anticoagulants (10.7 %) had much higher POH rates than patients not receiving anticoagulants (0.4 %, p < 0.01). Target organ, patient gender, procedure extent, antiplatelet use, and anticoagulant use were included on logistic regression to determine association with POH. Bilateral procedures, thyroidectomy, clopidogrel, oral, and injectable anticoagulants were all independently associated with POH. Conclusions POH occur more frequently after thyroidectomy and during bilateral procedures. Patients requiring clopidogrel or any anticoagulant coverage are at much higher risk for POH. These higher-risk patients should be considered for observation to ensure prompt POH recognition and intervention.

Perioperative risk factors for post‐thyroidectomy hematoma: Significance of pain and ketorolac usage

“…Complications after thyroidectomy are wellknown, but are rare; these include recurrent laryngeal nerve paralysis, hypoparathyroidism, and post-thyroidectomy hematoma. [1][2][3][4][5][6][7][8][9][10][11] In this study, we sought to identify perioperative risk factors for PH, with emphasis on perioperative hemodynamics and medications, along with well-known risk factors, such as sex, age, and type of operation. 2 Notably, PH is an uncommon, but life-threatening complication, which can induce upper airway obstruction, acute respiratory failure, and death.…”

Parathyroidectomy for the treatment of hyperparathyroidism: Thirty‐day morbidity and mortality

“…In addition to severe or permanent hypocalcemia as recently discussed, hematoma, recurrent laryngeal nerve injuries, and permanent hypoparathyroidism are among the more grave complications. Postoperative hemorrhage or hematoma is exceedingly rare in parathyroidectomies, with a reported rate as low as 0.1% . Injury to the recurrent laryngeal nerve are often addressed but most typically in the form of transient neuropraxia.…”

AHNS Series: Do you know your guidelines? Perioperative antithrombotic management in head and neck surgery

“…Although a relatively uncommon complication, if not promptly recognized and managed, a neck hematoma can be fatal. Thyroidectomy has a higher risk of postoperative bleeding than parathyroidectomy, and bilateral procedures also confer a higher risk of bleeding than unilateral procedures . Other risk factors for bleeding include older age, male sex, Graves' disease, prior thyroid surgery, and neck dissection …”

“…One retrospective analysis of 2514 patients undergoing thyroidectomy or parathyroidectomy found that postoperative hematoma rates were higher in patients receiving 325 mg of aspirin (0.8%), clopidogrel (2.2%), oral anticoagulants, such as warfarin or dabigatran (2.2%), and injectable anticoagulants, such as enoxaparin and heparin (10.7%) compared with patients not receiving antithrombotics (0.5%) or those receiving <325 mg of aspirin (0.1%). This study included patients taking antithrombotic medications within 2 weeks of surgery, including those who stopped the medications 5‐7 days before surgery . A meta‐analysis of bleeding after thyroidectomy included 6 studies with patients taking antithrombotic medications and found a nearly 2‐fold increased risk of postoperative hemorrhage (2.48% compared to the overall rate of 1.34%) .…”

“…Thyroidectomy has a higher risk of postoperative bleeding than parathyroidectomy, and bilateral procedures also confer a higher risk of bleeding than unilateral procedures. 19 Other risk factors for bleeding include older age, male sex, Graves' disease, prior thyroid surgery, and neck dissection. 18 One retrospective analysis of 2514 patients undergoing thyroidectomy or parathyroidectomy found that postoperative hematoma rates were higher in patients receiving 325 mg of aspirin (0.8%), clopidogrel (2.2%), oral anticoagulants, such as warfarin or dabigatran (2.2%), and injectable anticoagulants, such as enoxaparin and heparin (10.7%) compared with patients not receiving antithrombotics (0.5%) or those receiving <325 mg of aspirin (0.1%).…”