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Effectiveness of adherence to a preoperative antiplatelet and anticoagulation cessation protocol in cardiac surgery
Richard van Valen1, Menno van Gameren2, Mostafa M Mokhles1
1Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands.
Insights
Adhering to medication cessation protocols before cardiac surgery significantly reduces blood loss and the need for blood products. However, protocol adherence did not impact re-exploration rates or 30-day mortality in this study.
Area of Science:
- Cardiovascular Surgery
- Anesthesiology
- Hematology
Background:
- Minimizing blood loss after cardiac surgery is crucial for patient outcomes.
- The management of anticoagulants and platelet-inhibiting medications before surgery presents a complex balance between preventing thrombosis and reducing surgical bleeding.
Purpose of the Study:
- To investigate the effectiveness of adherence to a medication cessation protocol on reducing postoperative blood loss.
- To assess the influence of protocol violations on blood loss, blood product usage, surgical re-explorations, and 30-day mortality after elective cardiac surgery.
Main Methods:
- Prospective data collection from 1637 adult patients undergoing elective cardiac surgery between 2009 and 2013.
- Patients were divided into two groups: protocol adherence (n=1287) and protocol violation (n=350).
- Comparison of blood loss, blood product transfusion volumes, re-exploration rates, and 30-day mortality between the groups.
Main Results:
- Protocol violation was significantly associated with increased blood loss (median 350ml vs 275ml, P≤0.001) and higher consumption of fresh frozen plasma and thrombocyte transfusions.
- While protocol adherence led to lower blood loss and reduced blood product usage, there was no significant difference in re-exploration rates (6% vs 4%) or 30-day mortality (2% vs 1%).
- Stopping medication as per protocol did not result in an increased risk of thromboembolic events.
Conclusions:
- Adherence to a protocol for the cessation of anticoagulants and platelet-inhibiting medications effectively reduces postoperative blood loss and the need for blood products in cardiac surgery.
- The decision for surgical re-exploration and 30-day mortality were not significantly different between protocol adherence and violation groups.
- The study suggests that carefully managed medication cessation before surgery is safe and beneficial for reducing bleeding complications without compromising major clinical outcomes.
Objectives:
Reduction of blood loss after cardiac surgery remains challenging. The effectiveness of adherence to a protocol on cessation of anticoagulants and platelet-inhibiting medications was investigated together with the influence of protocol violations on blood loss after surgery, use of blood products, surgical re-explorations and 30-day mortality.
Methods:
Between 2009 and 2013, data were collected prospectively for all elective cardiac surgery procedures in adult patients (n = 1637). Two groups were distinguished: Group 1 adhered to the protocol for cessation or continuation of medication (n = 1287, 79%) and Group 2 violated the protocol (n = 350, 21%).
Results:
Median blood loss was 300 ml (interquartile range 175-500 ml). Eighty patients underwent re-exploration due to blood loss (5%). Thirty-day mortality was 2% (n = 27). Protocol violation was associated with increased blood loss [median 275 ml (175-475 ml) vs 350 ml (250-612); P ≤ 0.001] and with increased average use of fresh frozen plasma (226 ml vs 139 ml; P << 0.00001), red blood cell transfusion (115 ml vs 87 ml; P = 0.081) and thrombocyte transfusions (52 ml vs 37 ml; P = 0.0082). The number of re-explorations (4% vs 6%; P = 0.39) and mortality risk (1% vs 2%; P = 0.72) did not differ.
Conclusions:
Balancing the benefit of continuing platelet inhibitors or anticoagulants versus cessation before surgery remains challenging. Adherence to the protocol will lead to lower blood loss and in a lower consumption of blood products although the decision to go for re-exploration and 30-day mortality does not differ compared with the protocol violation. Stopping medication does not lead to thromboembolic events.
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