髋关节和膝关节置换术后的围手术期氯吡格雷和术后事件。
Perioperative clopidogrel and postoperative events after hip and knee arthroplasties.
机构信息
Department of Orthopedics, New England Baptist Hospital, Tufts University School of Medicine, 125 Parker Hill Avenue, Boston, MA 02120, USA.
出版信息
Clin Orthop Relat Res. 2012 May;470(5):1436-41. doi: 10.1007/s11999-012-2306-7. Epub 2012 Mar 9.
BACKGROUND
Hip and knee arthroplasties are widely performed and vascular disease among patients having these procedures is common. Clopidogrel is a platelet inhibitor that decreases the likelihood of thrombosis. It may cause intraoperative and postoperative bleeding, but its discontinuation increases the risk of vascular events. There is currently no consensus regarding the best perioperative clopidogrel regimen that balances these concerns.
QUESTIONS/PURPOSES: We determined (1) the relationship between time of perioperative clopidogrel administration and postoperative bleeding-related events after hip and knee arthroplasties and (2) patient characteristics or surgical factors that may predict these events.
METHODS
We retrospectively queried our inpatient pharmacy database for patients who received clopidogrel from 2007 to 2009 and identified 116 patients who underwent hip or knee arthroplasty. We recorded the time of perioperative clopidogrel administration, bleeding-related postoperative events, patient characteristics, and surgical factors.
RESULTS
Patients who withheld clopidogrel 5 or more days before hip or knee arthroplasty had lower rates of reoperation for infection and antibiotics prescribed for the surgical wound. Postoperative events did not vary with timing of clopidogrel resumption after surgery. Advanced age, an American Society of Anesthesiologists (ASA) score of 4, and revision surgery predicted increased readmission, reoperation for hematoma or infection, antibiotic use, and death.
CONCLUSIONS
Holding clopidogrel for at least 5 days before hip or knee arthroplasty may lower the rate of bleeding-related events. We found no increase in events when patients resumed clopidogrel immediately after surgery. Advanced age, ASA score of 4, and revision surgery may be risk factors for bleeding-related events.
LEVEL OF EVIDENCE
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
背景
髋关节和膝关节置换术广泛开展，此类手术患者的血管疾病较为常见。氯吡格雷是一种血小板抑制剂，可降低血栓形成的可能性。它可能导致术中及术后出血，但停药会增加血管事件的风险。目前，对于平衡这些顾虑的最佳围手术期氯吡格雷治疗方案，尚无共识。
问题/目的：我们旨在：（1）确定髋关节和膝关节置换术后围手术期氯吡格雷使用时间与术后出血相关事件之间的关系；（2）确定可能预测这些事件的患者特征或手术因素。
方法
我们回顾性查询了我院从 2007 年至 2009 年期间的住院药房数据库，筛选出 116 例行髋关节或膝关节置换术的患者。我们记录了围手术期氯吡格雷使用时间、与出血相关的术后事件、患者特征和手术因素。
结果
髋关节或膝关节置换术前停用氯吡格雷 5 天或以上的患者，其因感染而再次手术和因手术伤口而使用抗生素的几率较低。术后恢复使用氯吡格雷的时间与术后事件无明显关联。高龄、美国麻醉医师协会（ASA）评分 4 分和翻修手术预测了更高的再入院率、血肿或感染的再次手术、抗生素使用和死亡率。
结论
髋关节或膝关节置换术前至少停用氯吡格雷 5 天可能会降低出血相关事件的发生率。我们发现，患者在手术后立即恢复使用氯吡格雷，并不会增加相关事件的发生率。高龄、ASA 评分 4 分和翻修手术可能是出血相关事件的危险因素。
证据水平
IV 级，治疗性研究。欲了解完整的证据水平描述，请参见《作者指南》。
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