Steele Mitchell J, Fox John S, Fletcher John P, Grigg Leeanne E, Bell Gordon
Wollongong Hospital, 4 Mansion Pt Road, Grays Point, Sydney, NSW 2232, Australia.
ANZ J Surg. 2011 Nov;81(11):774-84. doi: 10.1111/j.1445-2197.2010.05631.x.
Patients medicated with clopidogrel who require orthopaedic surgery present a particular challenge. Whether in an emergency or elective situation the orthopaedic surgeon must balance the risks of ceasing clopidogrel versus the risk of increased bleeding that dual antiplatelet therapy generates.
This paper reviews the current published evidence regarding the risks of continuing clopidogrel, the risks of discontinuing clopidogrel and associated considerations such as venous thromboprophylaxis.
Little good quality evidence exists in regard to perioperative clopidogrel for orthopaedic surgery. Available evidence across non-cardiac and cardiac surgery were assessed and presented in regards to current practices, blood loss for orthopaedic operations, risks when continuing clopidogrel, risks of stopping clopidogrel and also the consideration of venous thromboembolism.
The patients at greatest risk, when discontinuing clopidogrel therapy, are those with drug eluting stents who may be at risk of stent thrombosis. Where possible, efforts should be made to continue clopidogrel therapy through the perioperative period, taking precautions to minimize bleeding. If the risk of bleeding is too high, antiplatelet therapy must be reinstated as soon as considered reasonable after surgery. In addition, patients on clopidogrel who sustain a fall or other general trauma need to be carefully assessed because of the possibility of occult bleeding, such as into the retroperitoneal space. Until more definitive evidence becomes available, this review aims to provide a guide for the orthopaedic surgeon in dealing with the difficult dilemma of the patient on clopidogrel therapy, recommending that orthopaedic surgeons take a team approach to assess the individual risks for all patients and consider continuation of clopidogrel therapy perioperatively where possible.
正在服用氯吡格雷且需要接受骨科手术的患者面临着特殊的挑战。无论是急诊还是择期手术，骨科医生都必须在停用氯吡格雷的风险与双联抗血小板治疗所带来的出血风险增加之间进行权衡。
本文回顾了目前已发表的关于继续使用氯吡格雷的风险、停用氯吡格雷的风险以及相关考虑因素（如静脉血栓预防）的证据。
关于骨科手术围手术期使用氯吡格雷的高质量证据很少。评估并呈现了非心脏手术和心脏手术的现有证据，内容涉及当前的做法、骨科手术的失血量、继续使用氯吡格雷的风险、停用氯吡格雷的风险以及静脉血栓栓塞的考虑因素。
停用氯吡格雷治疗时风险最高的患者是那些使用药物洗脱支架的患者，他们可能有支架血栓形成的风险。在可能的情况下应努力在围手术期继续使用氯吡格雷治疗，并采取预防措施将出血风险降至最低。如果出血风险过高，术后一旦认为合理就必须尽快恢复抗血小板治疗。此外，因可能存在隐匿性出血（如腹膜后出血），服用氯吡格雷的患者发生跌倒或其他全身创伤时需要仔细评估。在获得更确凿的证据之前，本综述旨在为骨科医生处理服用氯吡格雷治疗的患者这一难题提供指导，建议骨科医生采取团队协作的方式评估所有患者的个体风险，并尽可能在围手术期考虑继续使用氯吡格雷治疗。
