Introduction Ce qui a permis la RRAC (Recuperation Rapide Apres Chirurgie), voire l’ambulatoire d... more Introduction Ce qui a permis la RRAC (Recuperation Rapide Apres Chirurgie), voire l’ambulatoire dans cette chirurgie sont : – L’evolution des techniques chirurgicales avec la chirurgie mini invasive qui permet une cicatrice plus petite mais surtout ne necessite aucune section musculaire. – Les techniques d’analgesie multimodales associant les blocs anesthesiques, infiltrations et plusieurs antalgiques qui permettent de diminuer les opioides (donc les nausees et vomissements…) mais surtout permettent de marcher des la sortie de la salle de reveil. – La strategie transfusionnelle qui permet de traiter toute anemie pre et postoperatoire avec reduction drastique du saignement par l’utilisation de l’acide tranexamique systematique. Compte tenu de ces evolutions, on se pose legitimement des questions sur la thrombo-prophylaxie et les nouvelles recommandations europeennes (Eur J Anaesthesiol 2018 ; 35:134–138) vont dans ce sens. Aujourd’hui on se pose 5 questions : – Faut-il reduire la duree; – Proposer une strategie « hybride » agressive puis allegee apres 5 jours; – Proposer une prophylaxie ciblee en fonction d’un score; – Proposer une prophylaxie decalee dans le temps; – Choisir une autre molecule comme l’aspirine pour reduire les couts. Reduire la duree Si on ne prend en compte que les evenements symptomatiques, comme cela est fait dans les dernieres recommandations, il est justifie de reduire la duree dans la PTG a 10 jours par exemple. En revanche, apres PTH, il n’existe aucune etude randomisee demontrant que la reduction de la duree a l’hospitalisation ou a 1 semaine, comme cela est suggere dans ces recommandations, n’augmente pas le risque d’EP fatale. En effet, ces EP surviennent essentiellement apres la sortie du patient. Strategie hybride L’etude EPCAT II (N Engl J Med 2018;378:699–707) est une etude randomisee, double aveugle qui apres 5 jours de rivaroxaban 10 mg a randomise 2 groupes, 1 sous aspirine et 1 sous rivaroxaban 10 mg. Les resultats montrent une absence de difference significative sur efficacite (seulement sur TVP proximales et EP) et saignement. Donc, l’avantage est une diminution du cout, mais contrairement a notre attente une augmentation non significative des saignements sous aspirine. Proposer une strategie ciblee en fonction du score Ceci est aussi recommande pour evaluer le risque patient. Le seul score valide est celui de Caprini et cela parait vraiment interessant de l’appliquer. Cependant, compte tenu de l’âge et de la duree de la chirurgie, le risque est souvent eleve dans ce type de chirurgie. Proposer une prophylaxie decalee dans le temps Le risque hemorragique en postoperatoire est tres important les premieres 24 h (fibrinolyse) alors que le risque thrombotique apparait apres. On sait aussi qu’il est necessaire en postoperatoire de retarder la premiere injection d’anticoagulant pour permettre une bonne hemostase. Les etudes avec l’apixaban ont demontre que retarder le debut de l’anticoagulation au lendemain matin permettait, tout en gardant une meilleure efficacite, de diminuer le saignement. Cela me parait une approche tres interessante. Choisir une autre molecule comme l’aspirine Ceci est recommande pour les faibles risques patients, cependant, il est aussi suggere d’associer une IPC, difficile dans la RAC. Le nombre limite d’etudes randomisees ne permet de determiner ni la dose, ni la duree comme cela est precise dans les recommandations. Conclusions Il faut evoluer, cela veut dire reperer les patients a bas risque pour diminuer la prophylaxie. Il faut aussi s’assurer que le patient rentre a son domicile deambulera vraiment et se contentera pas du fameux lit-fauteuil-kine. A nous de les trouver. En attendant, les etudes randomisees avec un effectif suffisant compte tenu du peu d’evenements doivent etre realisees pour eviter une prophylaxie lourde a tous les patients pour un risque d’evenement grave
Anaesthesia, critical care & pain medicine, Jan 5, 2018
The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemos... more The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals for the management of antiplatelet therapy in patients undergoing elective invasive procedures. The proposals were discussed and validated by a vote; all proposals but one could be assigned with a high strength. The management of antiplatelet therapy is based on their indication and the procedure. The risk of bleeding related to the procedure can be divided into high, moderate and low categories depending on the possibility of performing the procedure in patients receiving antiplatelet agents (none, monotherapy and dual antiplatelet therapy respectively). If discontinuation of antiplatelet therapy is indicated before the procedure, a last intake of aspirin, clopidogrel, ticagrelor and prasugrel 3, 5, 5 and 7 days before surgery respectively ...
Orthopaedics & Traumatology: Surgery & Research, 2016
The elderly population is increasing worldwide, associated with an increase in diseases related t... more The elderly population is increasing worldwide, associated with an increase in diseases related to aging, such as hip fractures. These patients are sometimes treated with clopidogrel. There are no arguments at present to clearly determine the risk/benefit ratio of early surgical management of traumatic hip fractures in patients treated with clopidogrel (perioperative blood loss, postoperative complications). The goal of this systematic review of the literature was to show that early surgical management (< 48 h) of patients treated with clopidogrel does not increase postoperative morbidity or mortality. Systematic review of the literature: level of evidence IV. A bibliographic search was performed in July 2015 in PubMed, Embase and Cochrane databases using the MeSh keywords "Clopidogrel or Plavix ® " AND "hip fracture". Two of the authors analyzed 48 articles based on the title and abstract. Twenty-one articles were selected and read completely with an analysis of the references. Nine articles were chosen. Early surgical management (< 48 h) of patients receiving clopidogrel did not increase mortality at 30 days, 3 months or 1 year (between 25 and 30% mortality at 1 year) and did not result in an increase in perioperative bleeding. The risk/benefit ratio of early surgical management of patients with hip fractures receiving clopidogrel is good; morbidity and mortality are not increased in these patients if surgery is performed immediately or less than 48 h after admission. Level of evidence: IV.
A prospective clinical trial has been carried out to test the efficacy and tolerance of a low mol... more A prospective clinical trial has been carried out to test the efficacy and tolerance of a low molecular weight heparin (Tedelparin, K.abi*) in surgery involving a high risk of thromboembolic complications. Fifty elderly consecutive patients suffering from fractured hip surgery were enrolled (mean age: 74,8 y.; male/female: 22/28; ostheosynthesislprothesis: 27/23; general anaesthesia/regional anaesthesia: 43/7). They received Tedelparin subcutaneously-5000 IU AXa-once daily for a minimal period of 21 days, since admission. Efficacy was assessed by bilateral venography performed on the 10th postoperative day. The incidence of deep venous thrombosis (DVT) was 22% with a mid-p corrected 95% confidence interval ranging from 12 to 36% (proximal DVT 6%; distal DVT 16%; Marder scoring: 3 to 16, mean: 6,6). Clinical evidence of pulmonary embolism or mortality was not observed in this series of 50 patients. lntraoperative blood loss was 384 ml (sd: 185) and total blood loss was 684 ml (sd: 182). Average transfusion requierements during hospitalization were 0,44 u/pt. Adverse effects including minor bleeding complications and moderate wound hematomas were observed in 7 patients. Major wound hematomas occurred in 2 patients and one other developed an heparin induced thrombocytopenia syndrome. The effectiveness of the different low molecular weight heparins still remains to be quantified by comparative pharmacological studies. The prophylactic use of these treatments, whose theorical high tolerance level make suitable for geriatric surgery do not exempt them from the biological monitoring of platelet count as they do not exclude the risk of heparin induced thrombocytopenia syndrome.
Three new Direct Oral Anticoagulants (DOACs), rivaroxaban, apixaban and dabigatran etexilate are ... more Three new Direct Oral Anticoagulants (DOACs), rivaroxaban, apixaban and dabigatran etexilate are available on the French market. Management of DOAC-induced bleeding risk remains challenging. For elective procedures with high hemorrhagic risk, a last DOAC intake five days before procedure ensures complete elimination in all patients. Heparin bridging therapy should be proposed only to patients at high thrombotic risk. For elective procedures with low hemorrhagic risk, the DOAC intake of the night before procedure should be omitted. For urgent procedures with high bleeding risk, DOAC plasmatic concentration can be helpful: concentration lower than 30ng/mL should enable performing the procedure; a high concentration is associated with a higher bleeding risk, especially if higher than 400ng/mL. In case of massive bleeding, no antidote is approved yet; activated prothrombin concentrates or non-activated 4-factors prothrombin concentrates could be considered.
Conclusions: This study suggests that even though the hypothermia period was relatively short, ha... more Conclusions: This study suggests that even though the hypothermia period was relatively short, haemostatic mechanism was impaired. Our data indicate an increased thrombotic and fibrinolytic tendency. Major trauma and abdominal surgery are related to hypothermia, usually of a duration longer than 60 minutes. Coagulation defects are relatively early effects of hypothermia; they should be either prevented or corrected promptly, well before standard laboratory tests or clinical signs indicate the disorder.
Annales Françaises d'Anesthésie et de Réanimation, 2011
Article spé cial Chirurgies et actes invasifs chez les patients traité s au long cours par un ant... more Article spé cial Chirurgies et actes invasifs chez les patients traité s au long cours par un anticoagulant oral anti-IIa ou anti-Xa direct Propositions du Groupe d'inté rêt en hé mostase pé riopé ratoire (GIHP) et du Groupe d'é tudes sur l'hé mostase et la thrombose (GEHT) §, § § Surgery and invasive procedures in patients on long-term treatment with oral direct thrombin or factor Xa inhibitors
Journal of Bone & Joint Surgery, British Volume, 2011
RECORD3 was a multicentre, phase III study designed to investigate the efficacy and safety of riv... more RECORD3 was a multicentre, phase III study designed to investigate the efficacy and safety of rivaroxaban–a novel, oral, once-daily, direct Factor Xa inhibitor–compared with subcutaneous enoxaparin for thromboprophylaxis in patients undergoing total knee arthroplasty (TKA).
Duration of action of the second dose was 28 ± 2 min, and 35 ± 2 min. TIme to spontaneous recover... more Duration of action of the second dose was 28 ± 2 min, and 35 ± 2 min. TIme to spontaneous recovery to TH 50% was 41 ± 4 min, TOF = 17 ± 1%, and 45 ± 3 min, 18 ± 1.5% respectively. The requirement in Norcuron, to maintain adequate NMB, was 0.31 mglkg and 0.24 mglkg. Patients undergoing splenectomy have an increased requirement for nondepolarizing muscle relaxants. Safe practice dictates that relaxants be titrated to clinical effects by monitoring neuromuscular function in patients with hematology disorders. References
Autologous blood transfusion techniques are the principal means of reducing allogeneic blood expo... more Autologous blood transfusion techniques are the principal means of reducing allogeneic blood exposure. Those techniques were developed in order to prevent the risk of contamination by viruses, mainly HVB, HCV and HIV. However that risk has become so small that all studies show an exorbitant cost/efficiency ratio. Autologous blood transfusion would therefore be of no interest in terms of public health but a recent experimental study suggested a possible transmission of the BSE agent through blood. Until the matter is settled, the precaution principle means we should prefer alternative techniques to allogeneic blood whenever possible, hence a renewed interest in autologous transfusion.
Introduction Ce qui a permis la RRAC (Recuperation Rapide Apres Chirurgie), voire l’ambulatoire d... more Introduction Ce qui a permis la RRAC (Recuperation Rapide Apres Chirurgie), voire l’ambulatoire dans cette chirurgie sont : – L’evolution des techniques chirurgicales avec la chirurgie mini invasive qui permet une cicatrice plus petite mais surtout ne necessite aucune section musculaire. – Les techniques d’analgesie multimodales associant les blocs anesthesiques, infiltrations et plusieurs antalgiques qui permettent de diminuer les opioides (donc les nausees et vomissements…) mais surtout permettent de marcher des la sortie de la salle de reveil. – La strategie transfusionnelle qui permet de traiter toute anemie pre et postoperatoire avec reduction drastique du saignement par l’utilisation de l’acide tranexamique systematique. Compte tenu de ces evolutions, on se pose legitimement des questions sur la thrombo-prophylaxie et les nouvelles recommandations europeennes (Eur J Anaesthesiol 2018 ; 35:134–138) vont dans ce sens. Aujourd’hui on se pose 5 questions : – Faut-il reduire la duree; – Proposer une strategie « hybride » agressive puis allegee apres 5 jours; – Proposer une prophylaxie ciblee en fonction d’un score; – Proposer une prophylaxie decalee dans le temps; – Choisir une autre molecule comme l’aspirine pour reduire les couts. Reduire la duree Si on ne prend en compte que les evenements symptomatiques, comme cela est fait dans les dernieres recommandations, il est justifie de reduire la duree dans la PTG a 10 jours par exemple. En revanche, apres PTH, il n’existe aucune etude randomisee demontrant que la reduction de la duree a l’hospitalisation ou a 1 semaine, comme cela est suggere dans ces recommandations, n’augmente pas le risque d’EP fatale. En effet, ces EP surviennent essentiellement apres la sortie du patient. Strategie hybride L’etude EPCAT II (N Engl J Med 2018;378:699–707) est une etude randomisee, double aveugle qui apres 5 jours de rivaroxaban 10 mg a randomise 2 groupes, 1 sous aspirine et 1 sous rivaroxaban 10 mg. Les resultats montrent une absence de difference significative sur efficacite (seulement sur TVP proximales et EP) et saignement. Donc, l’avantage est une diminution du cout, mais contrairement a notre attente une augmentation non significative des saignements sous aspirine. Proposer une strategie ciblee en fonction du score Ceci est aussi recommande pour evaluer le risque patient. Le seul score valide est celui de Caprini et cela parait vraiment interessant de l’appliquer. Cependant, compte tenu de l’âge et de la duree de la chirurgie, le risque est souvent eleve dans ce type de chirurgie. Proposer une prophylaxie decalee dans le temps Le risque hemorragique en postoperatoire est tres important les premieres 24 h (fibrinolyse) alors que le risque thrombotique apparait apres. On sait aussi qu’il est necessaire en postoperatoire de retarder la premiere injection d’anticoagulant pour permettre une bonne hemostase. Les etudes avec l’apixaban ont demontre que retarder le debut de l’anticoagulation au lendemain matin permettait, tout en gardant une meilleure efficacite, de diminuer le saignement. Cela me parait une approche tres interessante. Choisir une autre molecule comme l’aspirine Ceci est recommande pour les faibles risques patients, cependant, il est aussi suggere d’associer une IPC, difficile dans la RAC. Le nombre limite d’etudes randomisees ne permet de determiner ni la dose, ni la duree comme cela est precise dans les recommandations. Conclusions Il faut evoluer, cela veut dire reperer les patients a bas risque pour diminuer la prophylaxie. Il faut aussi s’assurer que le patient rentre a son domicile deambulera vraiment et se contentera pas du fameux lit-fauteuil-kine. A nous de les trouver. En attendant, les etudes randomisees avec un effectif suffisant compte tenu du peu d’evenements doivent etre realisees pour eviter une prophylaxie lourde a tous les patients pour un risque d’evenement grave
Anaesthesia, critical care & pain medicine, Jan 5, 2018
The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemos... more The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals for the management of antiplatelet therapy in patients undergoing elective invasive procedures. The proposals were discussed and validated by a vote; all proposals but one could be assigned with a high strength. The management of antiplatelet therapy is based on their indication and the procedure. The risk of bleeding related to the procedure can be divided into high, moderate and low categories depending on the possibility of performing the procedure in patients receiving antiplatelet agents (none, monotherapy and dual antiplatelet therapy respectively). If discontinuation of antiplatelet therapy is indicated before the procedure, a last intake of aspirin, clopidogrel, ticagrelor and prasugrel 3, 5, 5 and 7 days before surgery respectively ...
Orthopaedics & Traumatology: Surgery & Research, 2016
The elderly population is increasing worldwide, associated with an increase in diseases related t... more The elderly population is increasing worldwide, associated with an increase in diseases related to aging, such as hip fractures. These patients are sometimes treated with clopidogrel. There are no arguments at present to clearly determine the risk/benefit ratio of early surgical management of traumatic hip fractures in patients treated with clopidogrel (perioperative blood loss, postoperative complications). The goal of this systematic review of the literature was to show that early surgical management (< 48 h) of patients treated with clopidogrel does not increase postoperative morbidity or mortality. Systematic review of the literature: level of evidence IV. A bibliographic search was performed in July 2015 in PubMed, Embase and Cochrane databases using the MeSh keywords "Clopidogrel or Plavix ® " AND "hip fracture". Two of the authors analyzed 48 articles based on the title and abstract. Twenty-one articles were selected and read completely with an analysis of the references. Nine articles were chosen. Early surgical management (< 48 h) of patients receiving clopidogrel did not increase mortality at 30 days, 3 months or 1 year (between 25 and 30% mortality at 1 year) and did not result in an increase in perioperative bleeding. The risk/benefit ratio of early surgical management of patients with hip fractures receiving clopidogrel is good; morbidity and mortality are not increased in these patients if surgery is performed immediately or less than 48 h after admission. Level of evidence: IV.
A prospective clinical trial has been carried out to test the efficacy and tolerance of a low mol... more A prospective clinical trial has been carried out to test the efficacy and tolerance of a low molecular weight heparin (Tedelparin, K.abi*) in surgery involving a high risk of thromboembolic complications. Fifty elderly consecutive patients suffering from fractured hip surgery were enrolled (mean age: 74,8 y.; male/female: 22/28; ostheosynthesislprothesis: 27/23; general anaesthesia/regional anaesthesia: 43/7). They received Tedelparin subcutaneously-5000 IU AXa-once daily for a minimal period of 21 days, since admission. Efficacy was assessed by bilateral venography performed on the 10th postoperative day. The incidence of deep venous thrombosis (DVT) was 22% with a mid-p corrected 95% confidence interval ranging from 12 to 36% (proximal DVT 6%; distal DVT 16%; Marder scoring: 3 to 16, mean: 6,6). Clinical evidence of pulmonary embolism or mortality was not observed in this series of 50 patients. lntraoperative blood loss was 384 ml (sd: 185) and total blood loss was 684 ml (sd: 182). Average transfusion requierements during hospitalization were 0,44 u/pt. Adverse effects including minor bleeding complications and moderate wound hematomas were observed in 7 patients. Major wound hematomas occurred in 2 patients and one other developed an heparin induced thrombocytopenia syndrome. The effectiveness of the different low molecular weight heparins still remains to be quantified by comparative pharmacological studies. The prophylactic use of these treatments, whose theorical high tolerance level make suitable for geriatric surgery do not exempt them from the biological monitoring of platelet count as they do not exclude the risk of heparin induced thrombocytopenia syndrome.
Three new Direct Oral Anticoagulants (DOACs), rivaroxaban, apixaban and dabigatran etexilate are ... more Three new Direct Oral Anticoagulants (DOACs), rivaroxaban, apixaban and dabigatran etexilate are available on the French market. Management of DOAC-induced bleeding risk remains challenging. For elective procedures with high hemorrhagic risk, a last DOAC intake five days before procedure ensures complete elimination in all patients. Heparin bridging therapy should be proposed only to patients at high thrombotic risk. For elective procedures with low hemorrhagic risk, the DOAC intake of the night before procedure should be omitted. For urgent procedures with high bleeding risk, DOAC plasmatic concentration can be helpful: concentration lower than 30ng/mL should enable performing the procedure; a high concentration is associated with a higher bleeding risk, especially if higher than 400ng/mL. In case of massive bleeding, no antidote is approved yet; activated prothrombin concentrates or non-activated 4-factors prothrombin concentrates could be considered.
Conclusions: This study suggests that even though the hypothermia period was relatively short, ha... more Conclusions: This study suggests that even though the hypothermia period was relatively short, haemostatic mechanism was impaired. Our data indicate an increased thrombotic and fibrinolytic tendency. Major trauma and abdominal surgery are related to hypothermia, usually of a duration longer than 60 minutes. Coagulation defects are relatively early effects of hypothermia; they should be either prevented or corrected promptly, well before standard laboratory tests or clinical signs indicate the disorder.
Annales Françaises d'Anesthésie et de Réanimation, 2011
Article spé cial Chirurgies et actes invasifs chez les patients traité s au long cours par un ant... more Article spé cial Chirurgies et actes invasifs chez les patients traité s au long cours par un anticoagulant oral anti-IIa ou anti-Xa direct Propositions du Groupe d'inté rêt en hé mostase pé riopé ratoire (GIHP) et du Groupe d'é tudes sur l'hé mostase et la thrombose (GEHT) §, § § Surgery and invasive procedures in patients on long-term treatment with oral direct thrombin or factor Xa inhibitors
Journal of Bone & Joint Surgery, British Volume, 2011
RECORD3 was a multicentre, phase III study designed to investigate the efficacy and safety of riv... more RECORD3 was a multicentre, phase III study designed to investigate the efficacy and safety of rivaroxaban–a novel, oral, once-daily, direct Factor Xa inhibitor–compared with subcutaneous enoxaparin for thromboprophylaxis in patients undergoing total knee arthroplasty (TKA).
Duration of action of the second dose was 28 ± 2 min, and 35 ± 2 min. TIme to spontaneous recover... more Duration of action of the second dose was 28 ± 2 min, and 35 ± 2 min. TIme to spontaneous recovery to TH 50% was 41 ± 4 min, TOF = 17 ± 1%, and 45 ± 3 min, 18 ± 1.5% respectively. The requirement in Norcuron, to maintain adequate NMB, was 0.31 mglkg and 0.24 mglkg. Patients undergoing splenectomy have an increased requirement for nondepolarizing muscle relaxants. Safe practice dictates that relaxants be titrated to clinical effects by monitoring neuromuscular function in patients with hematology disorders. References
Autologous blood transfusion techniques are the principal means of reducing allogeneic blood expo... more Autologous blood transfusion techniques are the principal means of reducing allogeneic blood exposure. Those techniques were developed in order to prevent the risk of contamination by viruses, mainly HVB, HCV and HIV. However that risk has become so small that all studies show an exorbitant cost/efficiency ratio. Autologous blood transfusion would therefore be of no interest in terms of public health but a recent experimental study suggested a possible transmission of the BSE agent through blood. Until the matter is settled, the precaution principle means we should prefer alternative techniques to allogeneic blood whenever possible, hence a renewed interest in autologous transfusion.
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