Klopidogrel kullanan kalça kırıklı hastalarda erken cerrahi uygundur

Öz

Amaç: Antiplatelet tedavi alırken kalça kırığı gelişen hastaların cerrahi müdahale zamanlaması tartışmalı bir durumdur. Klopidogrel birçok hastalığın tedavisinde yaygın olarak kullanılan antiplatelet bir ilaçtır. Bu çalışmada klopidogrel tedavisi alırken kalça kırığı olan hastaların cerrahi müdahale sonuçlarını karşılaştırmayı amaçladık.

Çalışma planı: 2009 ile 2014 yılları arasında ileri yaş femur boyun kırığı nedeni ile açık cerrahi uygulanan hastalar geriye dönük olarak tarandı. Çalışmaya 211 hasta dahil edildi. Hastalar; klopidogrel kullanan ve ilk 48 saat içinde opere edilenler (grup 1, 74 hasta), klopidogrel kullanan ve beşinci günden sonra opere edilen (grup 2, 55 hasta) ve herhangi bir antiagregan kullanmayan (grup 3, 82 hasta) olarak üç gruba ayrıldı. Gruplar kan transfüzyon miktarı, yatış süresi, komplikasyon ve mortalite açısından karşılaştırıldı.

Bulgular: Gruplar arasında yaş cinsiyet operasyon öncesi hemoglobin değerleri ve ASA skorları açısından anlamlı fark tespit edilemedi. Birinci gruptaki hastaların daha fazla kan transfüzyonu ihtiyacı oldu (p=0.023). İkinci grupta hastanede kalış süresi daha yüksek idi (p<0.01) ve daha yüksek oranda (%25.4) komplikasyon görüldü (p<0.01). İkinci gruptaki hastalarda ilk otuz gün içinde ve ilk üç ay içinde ölüm oranı diğer gruplara göre daha yüksek bulundu (sırasıyla, p=0.031, p<0.01).

Çıkarımlar: Kalça kırıklarında cerrahi müdahale klopidogrel kullanan hastalarda ertelenmemelidir.

 

 

DOI: 10.3944/AOTT.2015.14.0160

Bu özet, makalenin henüz redaksiyonu tamamlanmamış haline aittir ve bilgi verme amaçlıdır. Yayın aşamasında değişiklik gösterebilir.

Anahtar Kelimeler

• Klopidogrel; erken cerrahi; kalça kırığı.

Early surgery is feasible in patients with hip fractures who are on clopidogrel therapy

Abstract

Objective: Timing of surgery in hip fracture patients using antiplatelet agents is a controversial issue. Clopidogrel is an antiplatelet drug widely used in the treatment of many diseases. In this study, we aimed to investigate the outcomes of early surgery in hip fracture patients using clopidogrel.
Methods: Elderly patients with femoral neck fractures who underwent open surgery between 2009 and 2014 were evaluated. Two hundred and eleven patients were included in the study. Patients were separated into 3 groups. Group 1 was constituted of patients using clopidogrel who had been operated on within 48 h after admission (n=74), Group 2 was constituted of patients using clopidogrel who had been operated on after the fifth day of admission (n=55), and Group 3 was constituted of patients not using clopidogrel who had been operated on within 48 h after admission (n=83). Length of hospital stay, amount of blood transfusion, rate of complication, and mortality rate were assessed for comparison of groups.
Results: Age, sex, preoperative hemoglobin values, and ASA scores were not different between the groups. Amount of blood transfusions was higher in Group 1 (p=0.023). Duration of hospital stay was longer in Group 2 (p<0.01), as was complication rate (25.4%) (p<0.01). Mortality within 30 days and within the first 3 months post-surgery was significantly higher in Group 2 (p=0.031, p<0.01; respectively).
Conclusion: Surgery should not be postponed in hip fracture patients using clopidogrel.

Keywords

• Clopidogrel
• early surgery
• hip fracture

References

1. Kannus P, Parkkari J, Sievänen H, Heinonen A, Vuo- ri I, Järvinen M. Epidemiology of hip fractures. Bone 1996;18(1 Suppl):57–63.
2. Haentjens P, Magaziner J, Colón-Emeric CS, Vander- schueren D, Milisen K, Velkeniers B, et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med 2010;152(6):380–90.
3. Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? System- atic review, meta-analysis, and meta-regression. Can J An- aesth 2008;55:146–54.
4. Bhatt DL, Bertrand ME, Berger PB, L’Allier PL, Moussa I, Moses JW, et al. Meta-analysis of randomized and registry comparisons of ticlopidine with clopidogrel after stenting. J Am Coll Cardiol 2002;39:9–14.
5. Leong JY, Baker RA, Shah PJ, Cherian VK, Knight JL. Clopidogrel and bleeding after coronary artery bypass graft surgery. Ann Thorac Surg 2005;80:928–33.
6. Stone DH, Goodney PP, Schanzer A, Nolan BW, Adams JE, Powell RJ, et al. Clopidogrel is not associated with ma- jor bleeding complications during peripheral arterial sur- gery. J Vasc Surg 2011;54:779–84.
7. Steele MJ, Fox JS, Fletcher JP, Grigg LE, Bell G. Clopi- dogrel dilemma for orthopaedic surgeons. ANZ J Surg 2011;81:774–84.
8. Wordsworth DR, Halsey T, Griffiths R, Parker MJ. Clopi- dogrel has no effect on mortality from hip fracture. Injury 2013;44:743–6.

9. Cruden NL, Harding SA, Flapan AD, Graham C, Wild SH, Slack R, et al. Previous coronary stent implantation and cardiac events in patients undergoing noncardiac sur- gery. Circ Cardiovasc Interv 2010;3:236–42.
10. Leong JY, Baker RA, Shah PJ, Cherian VK, Knight JL. Clopidogrel and bleeding after coronary artery bypass graft surgery. Ann Thorac Surg 2005;80:928–33.
11. Feit F, Voeltz MD, Attubato MJ, Lincoff AM, Chew DP, Bittl JA, et al. Predictors and impact of major hemor- rhage on mortality following percutaneous coronary in- tervention from the REPLACE-2 Trial. Am J Cardiol 2007;100:1364–9.
12. Wijns W, Kolh P, Danchin N, Di Mario C, Falk V, Fol- liguet T, et al. Guidelines on myocardial revascularization. Eur Heart J 2010;31:2501–55.
13. Zuckerman JD. Hip fracture. N Engl J Med 1996;334:1519–25.
14. Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, et al. Effect of early surgery after hip fracture on mortality and complications: systematic re- view and meta-analysis. CMAJ 2010;182:1609–16.
15. Orosz GM, Magaziner J, Hannan EL, Morrison RS, Koval K, Gilbert M, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA 2004;291:1738–43.
16. Collinge CA, Kelly KC, Little B, Weaver T, Schuster RD. The effects of clopidogrel (Plavix) and other oral antico- agulants on early hip fracture surgery. J Orthop Trauma 2012;26:568–73.
17. Wilson D, Cooke EA, McNally MA, Wilson HK, Yeates A, Mollan RA. Changes in coagulability as measured by thrombelastography following surgery for proximal femo- ral fracture. Injury 2001;32:765–70.
18. Johansen A, White J, Turk A. Clopidogrel therapy-impli- cations for hip fracture surgery. Injury 2008;39:1188–90.
19. Lavelle WF, Demers Lavelle EA, Uhl R. Operative delay for orthopedic patients on clopidogrel (plavix): a complete lack of consensus. J Trauma 2008;64:996–1000.
20. Harty JA, McKenna P, Moloney D, D’Souza L, Master- son E. Anti-platelet agents and surgical delay in elderly patients with hip fractures. J Orthop Surg (Hong Kong) 2007;15:270–2.