Fish Oil and Perioperative Bleeding

Abstract

Background: Fish oil is among the most common natural supplements for treatment of hypertriglyceridemia or prevention of cardiovascular disease. However, ongoing concerns about possible bleeding risk has led to recommendations that patients stop taking fish oil prior to surgery and/or delay in elective procedures for patients taking fish oil Methods and Results: We tested the effect of fish oil supplementation on peri-operative bleeding in a multinational, placebo-controlled trial involving 1516 patients who were randomized to perioperative fish oil (EPA + DHA; 8–10 g over 2–5 days preoperatively, then 2 g/day postoperatively) or placebo. Primary outcome was major peri-operative bleeding as defined by the Bleeding Academic Research Consortium (BARC). Secondary outcomes include peri-operative bleeding per TIMI and ISTH definitions, chest tube output, and total units of blood transfused. Mean(SD) participants age was 63(13) years, and planned surgery included CABG (52%) and valve surgery (50%). The primary outcome occurred in 92 patients (6.1%). Compared to placebo, risk of BARC bleeding was not higher in the fish oil group: OR=0.81, 95%CI=0.53–1.24; absolute risk difference=1.1% lower (95%CI= −3.0 to 1.8%). Similar findings were seen for secondary bleeding definitions. The total units of blood transfused were significantly lower in the fish oil group compared to placebo (mean=1.61 vs 1.92, p<0.001). Evaluating achieved plasma phospholipid n-3-PUFA levels with supplementation (on the morning of surgery), higher levels were associated with lower risk of BARC bleeding, with substantially lower risk in the third (OR=0.30 [95%CI, 0.11–0.78]) and fourth (0.36 [95%CI, 0.15–0.87]) quartiles, compared with the lowest quartile. Conclusions: Fish oil supplementation did not increase peri-operative bleeding; and reduced the number of blood transfusions. Higher achieved n-3-PUFA levels were associated with lower risk of bleeding. These novel findings support the need for reconsideration of current recommendations to stop fish oil or delay procedures prior to cardiac surgery. Clinical Trial Registration URL: http://Clinicaltrials.gov Unique identifier: NCT00970489

Supervised machine learning models and protein-protein interaction network analysis of gene expression profiles induced by omega-3&nbsp;polyunsaturated fatty acids

“…EPA and DHA are also well-known in alleviating symptoms of different mental illnesses starting from anxiety and depression to bipolar disorder and schizophrenia [24]. Recently, the PUFA effect on preoperative bleeding has been estimated in the randomized placebo-controlled clinical trial to be associated with a lower risk of bleeding at higher sh oil levels [25]. This information might support our ndings that PUFAs could potentially trigger the upregulation of complement/coagulation cascade genes, reconsidering current recommendations not to use sh oil before cardiac surgery [26].…”

Omega-3 Fatty Acids in Pregnancy—The Case for a Target Omega-3 Index

“…A bleeding tendency caused by EPA and DHA was not seen in the Cochrane meta-analysis mentioned [16]. In an analysis of postoperative bleeding, higher levels of EPA and DHA were associated with fewer bleeding episodes [71]; after a thromboembolic event, patients on anticoagulation lived longer, but had no more bleeding episodes than patients with a lower Omega-3 Index [72]. However, in two cardiovascular trials with high doses of EPA, bleeding episodes occurred 0.1% more frequently per year in verum than in placebo [73,74].…”

Preoperative Management of Surgical Patients Using Dietary Supplements

“…Prior concerns about bleeding risk have not been borne out in prospective studies. [51][52][53] Supplements That May Cause CNS Depression Due to the lack of information about their pharmacokinetics, and their known potential to exacerbate CNS depression in the perioperative period, the group believes the following should ideally be held for 2 weeks before surgery: Kava, lemon balm, and skullcap.…”

“…Intake of >3 g/day associated with decreased platelet aggregation and increased risk of bleeding. 50 Newer data suggest no increased risk with fish oil [51][52][53] and potentially lower blood loss.…”