Perioperative management of clopidogrel therapy: the effects on in-hospital cardiac morbidity in older patients with hip fractures

Collyer, Thomas; Reynolds, Howard; Truyens, E.; Kilshaw, Lindsey; Corcoran, Tomás

doi:10.1093/bja/aer288

Cited by 37 publications

(35 citation statements)

References 18 publications

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“…At our hospital we are trying to improve early access to FIB in order to avoid the complications described above, and are developing a training program to enable emergency staff to perform FIBs at their initial assessment. This has been shown to be achievable and provides safe and effective analgesia in the emergency department [3].We agree with the accompanying editorial calling for a more prominent role for nerve blocks in the pain management of this patient population [4]. We also suggest that the delayed use of FIBs on the analgesic ladder is incorrect, and will potentially create a serious complication that will tarnish the reputation of a very useful block.…”

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confidence: 67%

“…Clopidogrel should not be stopped and there is some evidence that blood loss is not increased when fractured femur patients undergo surgery [2]. There is also evidence that stopping the drug and waiting may actually harm the patient [3]. Options for regional anaesthesia will be limited but general anaesthesia is a reasonable option.…”

Section: A Replymentioning

confidence: 99%

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confidence: 99%

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Griffiths

2012

Anaesthesia

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Excellence (NICE) guidelines issued in June 2011 [2].Within our institution we have an established a fascia iliaca block (FIB) service provided by Trauma and Orthopaedic Nurse Practitioners for patients with a fractured neck of femur. We find this nerve block very useful for pain control, and patients subsequently require minimal systemic analgesia. During a recent audit the only complication noted, other than block failure, was excessive sedation following administration of an effective FIB. Without exception, these cases had received their FIB after significant amounts of morphine had been given for pain control. Approximately 1 h after FIB, naloxone was required to reverse the excessive opioid sedation. We are concerned that the NICE guidelines advocate a delayed approach to FIB placement whereas the AAGBI guidelines suggest a 'single shot ⁄ continuous nerve block may be successfully administered' [1,2]. If the NICE guidelines are rigorously applied then the FIB should be used after paracetamol and opioid administration if pain is still an issue. This approach increases the risk of complications associated with FIB and delayed opioid sedation.We strongly believe that the correct timing for the FIB is immediately after radiographic confirmation of the diagnosis, or earlier in cases of high clinical suspicion, and FIB should be offered to all in whom it is not contraindicated. This maximises pain relief in the most painful early period and negates the need for strong systemic analgesia in this physiologically frail group. At our hospital we are trying to improve early access to FIB in order to avoid the complications described above, and are developing a training program to enable emergency staff to perform FIBs at their initial assessment. This has been shown to be achievable and provides safe and effective analgesia in the emergency department [3].We agree with the accompanying editorial calling for a more prominent role for nerve blocks in the pain management of this patient population [4]. We also suggest that the delayed use of FIBs on the analgesic ladder is incorrect, and will potentially create a serious complication that will tarnish the reputation of a very useful block.

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confidence: 67%

Section: A Replymentioning

confidence: 99%

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Griffiths

2012

Anaesthesia

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“…22 Furthermore, Collyer et al stated that no haematomas were reported for 25 hip fracture patients on clopidogrel who had spinal anaesthesia. 23 The plasma half-life of clopidogrel is approximately six hours. 24 Its concentration falls to <2% after 24 hours.…”

Section: Discussionmentioning

confidence: 99%

Decision making on timing of surgery for hip fracture patients on clopidogrel

Purushothaman

Webb

Weusten

et al. 2016

annals

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Patients taking clopidogrel who sustain a fractured neck of femur pose a challenge to orthopaedic surgeons. The aim of this study was to determine whether delay to theatre for these patients affects drop in haemoglobin levels, need for blood transfusion, length of hospital stay and 30-day mortality. A retrospective review of all neck of femur patients admitted at two centres in the North East of England over 3 years revealed 85 patients.Patients were divided into two groups depending on whether they were taking clopidogrel alone (C) or with aspirin (CA). Haemoglobin drop was significantly different in the CA group that was operated on early (CA1) versus the group for which surgery was delayed by over 48 hours (CA2): 3.3g/dl and 1.9g/dl respectively (p=0.01). The mean inpatient stay in group C was 35.9 days while in group CA it was 19.9 days (p=0.002). The mean length of stay in group CA2 (26.7 days) was significantly longer than for CA1 patients (14.1 days) (p=0.01). There were no significant differences in mortality or wound complications.Hip fracture patients on clopidogrel can be safely operated on early provided they are medically stable. Bleeding risk should be borne in mind in those patients on dual therapy with aspirin. KEYWORDSHip fracture -Clopidogrel -Aspirin -Delay to surgery Clopidogrel is a thienopyridine that irreversibly binds to platelets inhibiting aggregation. It is used commonly with or without aspirin for primary and secondary prevention of cardio and cerebrovascular disease. Given the prevalence of coronary disease, advances in coronary intervention for stable and unstable cardiac as well as stroke disease, it is no surprise that the number of patients admitted to hospital on dual antiplatelet therapy (DAPT) as well as other newer anticoagulant agents is rising. The timing of operative intervention for hip fracture patients on antiplatelet agents poses a significant challenge to the multidisciplinary team managing these complex patients. Hip fracture patients tend to be older with co-morbidities. There is consensus in the orthopaedic community that if feasible and indicated, surgery should be carried out at the earliest opportunity followed by early mobilisation. Patients taking DAPT, clopidogrel alone or other anticoagulants have an elevated bleeding risk in the perioperative period. These patients have a higher risk of bleeding if operated on early while delaying surgery is associated with increased risk of morbidity and mortality. There is a lack of consensus among orthopaedic teams for timing of operation, with some surgeons choosing to stop their patients' antiplatelet treatment and delay operative management. 3,4 There is a paucity of literature reporting the risks and benefits of operating on these patients. 5,6 This study sought to determine whether time to surgery influenced factors including drop in haemoglobin (Hb) levels, need for blood transfusion, duration of inpatient stay and 30-day mortality for patients who were admitted with a neck of femur fracture while taking cl...

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“…Increasing number of patients on clopidogrel therapy are presenting for urgent hip fracture surgery. Early withdrawal of clopidogrel has been shown to be associated with increased incidence of acute coronary events [13] .…”

Section: Discussionmentioning

confidence: 99%

Safety of combined lumbar and sacral plexus block in high risk patients undergoing fractured neck of femur repair under general anaesthesia

Dixit

Banerjee

Singh

2014

CRIM

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In this case series we present three high-risk patients with multiple co-morbidities listed for repair of fractured neck of femur with hemiarthroplasty under general anaesthesia. All three were administered combined unilateral lumbar plexus block (LPB) and sacral plexus block (SPB) for intra and post-operative analgesia. One patient presented with severe chronic obstructive pulmonary disease in combination with severe aortic stenosis. The second one had extensive medical history, was in fast atrial fibrillation (AF) and was actively taking clopidogrel. The last patient had an automatic implantable cardioverter defibrillator (AICD) for dilated cardiomyopathy secondary to ischaemic heart disease and was in left ventricular failure. All three patients had uneventful recovery and were discharged to the ward following their initial stay in the critical care unit. We discuss the evidence and controversies surrounding the techniques employed in these three difficult cases.

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Perioperative management of clopidogrel therapy: the effects on in-hospital cardiac morbidity in older patients with hip fractures

Cited by 37 publications

References 18 publications

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Decision making on timing of surgery for hip fracture patients on clopidogrel

Safety of combined lumbar and sacral plexus block in high risk patients undergoing fractured neck of femur repair under general anaesthesia

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