Peri-Operative Management of Patients with Proximal Femoral Fractures on Clopidogrel Current...
-
date post
21-Dec-2015 -
Category
Documents
-
view
220 -
download
6
Transcript of Peri-Operative Management of Patients with Proximal Femoral Fractures on Clopidogrel Current...
Peri-Operative Management of Patients with Proximal Femoral Fractures on Clopidogrel
Current Practice in UK Orthopaedic Departments
Inman D, Michla Y, Partington P
Kreibich Memorial Research Prize March 2007
Proximal Femoral Fractures
Common in the elderly Most common fractures alongside vertebrae
& distal radius Around 57,500 cases / year Numbers rising 59% of patients have comorbidities Overall mortality 33% in 1st year post-op
Balasegaram et al. Trends in Hospital Admissions from Fractures of the Hip & Femur in England. J. Public Health Med. 2001 Mar; 23(1): 11-17
J J W Roche, R T Wenn, O Sahota, C G Moran. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 2005;331:1374
Clopidogrel Bisulphate ( PlavixR )
Thebault JJ, Kieffer G, Lowe WS, Cariou R. Repeated dose pharmacodynamics of clopidogrel in healthy subjects. Semin Thromb Haemost 1999;25(Suppl 2):9 –14Leeksma C, Cohen J. Determination of the Lifespan of Human Blood Platelets using Labelled Diisoprpylfluorophosphonate. J Clin Invest 1956; 35(9): 964-9Billett et al. Antiplatelet & Arterial Thrombosis. Clin Ger Med 2006; 22: 57 – 74Weber et al. Recovery of Platelet Function after Discontinuation of Clopidogrel Treatment in Healthy Volunteers. Br J Clin Pharmacol 2001; 52: 333-6
• Potent platelet inhibitor
• Irreversibly inhibits ADP receptors on platelet membrane Causes a twofold increase in bleeding time Acts within 4-6 hours Active metabolite excreted in less than 24 hours
• Effects last for life of platelet (8-9 days)
• Normal platelet function noted 7 days after withdrawal
Clopidogrel Licence
Prevention of occlusive vascular events– Intolerance of aspirin– CVA– Non-ST segment elevation Acute Coronary Syndrome– Peripheral Vascular Disease
Post coronary stent insertion– Decreases risk of subacute stent occlusion– Prescribed for up to 1 year following insertion
(Bare Metal Stents vs Drug Eluting Stents)
NICE Press Release, July 2004 & NICE Guidelines, May 2005CAPRIE Steering committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348: 1329-39.CURE Trial investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. New England Journal of Medicine 2001; 345: 494-503.
Dawkins KD, Gershlick T, de Belder M et al. Percutaneous coronary intervention: recommendations for good practice and training. Heart2005;91;1-27
The Dilemma…
Increasing % of surgical patients on Clopidogrel
Elective surgery guidelines– cease Clopidogrel for 7-10 days pre-operatively to allow
return of normal platelet function
Patients with proximal femoral fractures– Elderly population bedridden and in pain– Mortality increases as delay to surgery increases– Delay of ≥ 4 days significantly increases mortality
Weller et al. The Effect of Hospital Type & Surgical Delay on Mortality after Sugery for Hip Fracture. J Bone Joint Surg (Br) 2005; 87-B: 361-6Moran et al. Early Mortality After Hip Fracture: Is Delay Before Surgery Important? J Bone Joint Surg (Am) 2005; 87-A(3): 483-9
Aims of Study
1. To establish current practice amongst Orthopaedic surgeons in the UK
2. To establish if practice of peri-operative withdrawal of Clopidogrel is evidence-based or anecdotal
3. To design an interim protocol for these patients pending further research
Materials and Methods
Postal questionnaire
Sent to each Orthopaedics & Trauma department in Great Britain
Questionnaire Does department have written protocol for trauma patients who are
taking Clopidogrel alone or Clopidogrel and Aspirin?
Do you;
Continue Clopidogrel and operate as soon as medically fit Stop Clopidogrel and operate as soon as medically fit Stop Clopidogrel and wait 10 days before surgery Other
Asked to indicate evidence for management
Free comments
Results (1)
244 questionnaires sent
139 orthopaedic departments responded (57% response rate)
15% of centres that responded have written guidelines
Results (2)
Continue clopidogrel andoperate when medically fit 19%
(26)Stop clopidogrel and operateas soon as medically fit 41%
(56)
Stop clopidogrel and wait 10 days 10%
(14)
Other 30% (41)
0 10 20 30 40 50
Other Policies (30%)
15 centres stop and wait 5-10 days 1 centre stops and waits 14 days
Local anaesthetic department requirement
2 centres had not heard of clopidogrel 10 centres took advice from the anaesthetic
department regarding timing of surgery 6 centres took advice from the
haematologists
Evidence Quoted
3 centres (2%) quoted published literature – 2 of these quoted the BNF
(Only gives advice for elective surgery)
7 centres (5%) reported anecdotal increased bleeding perioperatively if patient on clopidogrel
Clopidogrel and Emergency Surgery
No published orthopaedic data Increased peri-procedure blood loss reported
in cardiothoracic literature Intra-operative aprotinin therapy effective in
patients treated with clopidogrel <5 days before CABG surgery
Leong JY et al. Clopidogrel and bleeding after coronary artery bypass graft surgery. Ann Thorac Surg. 2005 Sep; 80(3): 928-33.Van der Linden J, Lindvall G, Sartipy U. Aprotinin Decreases Postoperative Bleeding and Number of Transfusions in Patients on Clopidogrel Undergoing CoronaryArtery Bypass Graft Surgery: A Double-Blind, Placebo-Controlled, Randomized Clinical Trial Circulation 2005;112;276-280
Blood Transfusion and the AnaesthetistGuidelines published by
The Association of Anaesthetists of Great Britain and IrelandDec 2005
…Clopidogrel is a pro-drug. The active metabolite circulates for approximately 18 hours after the most recent dose and permanently inhibits any platelets present during this time (whether endogenous or transfused). Platelet therapy during this time is unlikely to be helpful. If possible, emergency surgery is best delayed for at least 24 hours after the last dose of clopidogrel…
…The combination of platelet transfusions and aprotinin therapy has been used to decrease blood loss.
Conclusions
• Wide variation in practice
• Current practice based on anecdote
• Establish indication for Clopidogrel
• Further research required comparing outcome of early versus delayed surgery
Patient with #NOF on Clopidogrel
<1 year post coronary stent<1 year post coronary stentinsertioninsertion
Other indicationOther indication
Discuss with interventional cardiologist re. safety of stopping
ClopidogrelConsider continuing throughout
perioperative period
Stop Clopidogrel on admission
Work up for theatre as normal
Operate >24 hours following last doseAvoid spinal anaesthesia
Meticulous haemostasisPlatelet transfusion/ aprotinin available
Restart Clopidogrel on 2nd post-op day/ when local haemostasis acheived
Thank you(Prevention is better than cure)