Surgeon's guide to anticoagulant and antiplatelet medications part two: antiplatelet agents and perioperative management of long-term anticoagulation.

An increasing number of potent antiplatelet and anticoagulant medications are being used for the long-term management of cardiac, cerebrovascular, and peripheral vascular conditions. Management of these medications in the perioperative and peri-injury settings can be challenging for surgeons, mandating an understanding of these agents and the risks and benefits of various management strategies. In this two part review, agents commonly encountered by surgeons in the perioperative and peri-injury settings are discussed and management strategies for patients on long-term antiplatelet and anticoagulant therapy reviewed. In part one, we review warfarin and the new direct oral anticoagulants. In part two, we review antiplatelet agents and assessment of platelet function and the perioperative management of long-term anticoagulation and antiplatelet therapy.

A surgeon's guide to anticoagulant and antiplatelet medications part one: warfarin and new direct oral anticoagulant medications.

An increasing number of potent antiplatelet and anticoagulant medications are being used for the long-term management of cardiac, cerebrovascular, and peripheral vascular conditions. Management of these medications in the perioperative and peri-injury settings can be challenging for surgeons, mandating an understanding of these agents and the risks and benefits of various management strategies. In this two-part review, agents commonly encounter by surgeons in the perioperative and peri-injury settings are discussed and management strategies for patients on long-term antiplatelet and anticoagulant therapy reviewed. In part I, we review warfarin and the new direct oral anticoagulants. In part II, we review antiplatelet agents and assessment of platelet function and the perioperative management of long-term anticoagulant and antiplatelet therapy.

Should uncooperative trauma patients with suspected head injury be intubated?

In trauma patients with a suspicion for traumatic brain injury (TBI), a head computed tomography (CT) scan is imperative. However, uncooperative patients often cannot undergo imaging without sedation and may need to be intubated. Our hypothesis was that among mildly injured trauma patients, in whom there is a suspicion of a head injury, uncooperative patients have higher rates of TBI and intubation should be considered to obtain a CT scan. We found that uncooperative patients intubated for diagnostic purposes were more likely to have moderate to severe TBI than nonintubated patients (21.4 vs. 8.4%, P < 0.0001) and uncooperative behavior leading to intubation was an independent predictor of TBI (odds ratio, 2.5; 95% confidence interval, 1.5 to 4.5). Of patients with brain injury, intubated patients more often had a head abbreviated injury scale score of 4 (20.8 vs. 7.9%, P = 0.04). Uncooperative intubated patients had longer hospital stays (3.6 vs. 2.6 days, P = 0.003) and higher mortality (0.9 vs. 0.2%, P = 0.02) than nonintubated patients. Uncooperative behavior may be an early warning sign of TBI and the trauma surgeon should consider intubating uncooperative trauma patients if there is suspicion for brain injury based on the mechanism of their trauma.

Death or dialysis? The risk of dialysis-dependent chronic renal failure after trauma nephrectomy.

Although renal trauma is increasingly managed nonoperatively, severe renovascular injuries occasionally require nephrectomy. Long-term outcomes after trauma nephrectomy are unknown. We hypothesized that the risk of end-stage renal disease (ESRD) is minimal after trauma nephrectomy. We conducted a retrospective review of the following: 1) our university-based, urban trauma center database; 2) the National Trauma Data Bank (NTDB); 3) the National Inpatient Sample (NIS); and 4) the U.S. Renal Data System (USRDS). Data were compiled to estimate the risk of ESRD after trauma nephrectomy in the United States. Of the 232 patients who sustained traumatic renal injuries at our institution from 1998 to 2007, 36 (16%) underwent a nephrectomy an average of approximately four nephrectomies per year. The NTDB reported 1780 trauma nephrectomies from 2002 to 2006, an average of 356 per year. The 2005 NIS data estimated that in the United States, over 20,000 nephrectomies are performed annually for renal cell carcinoma. The USRDS annual incidence of ESRD requiring hemodialysis is over 90,000, of which 0.1 per cent (100 per year) of renal failure is the result of traumatic or surgical loss of a kidney. Considering the large number of nephrectomies performed for cancer, we estimated the risk of trauma nephrectomy causing renal failure that requires dialysis to be 0.5 per cent. National data regarding the etiology of renal failure among patients with ESRD reveal a very low incidence of trauma nephrectomy (0.5%) as a cause; therefore, nephrectomy for trauma can be performed with little concern for long-term dialysis dependence.

The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest.

BACKGROUND: The clinical utility of determining cardiac motion on ultrasound has been reported for patients presenting in pulseless medical cardiac arrest. However, the relationship between ultrasound-documented cardiac activity and the probability of surviving pulseless electrical activity has not been examined in populations with trauma. We hypothesized that cardiac activity on ultrasound predicts survival for patients presenting in pulseless traumatic arrest. METHODS: We conducted a retrospective analysis at our university-based urban trauma center of adult patients with trauma, who were pulseless on hospital arrival. Results of cardiac ultrasound performed during trauma resuscitations were compared with the electrocardiogram (EKG) rhythm and survival. RESULTS: Among 318 pulseless patients with trauma, 162 had both EKG tracings and a cardiac ultrasound, and 4.3% of these 162 patients survived to hospital admission. Survival was higher for those with cardiac motion than for those without it (23.5% vs. 1.9% for patients with EKG electrical activity, p = 0.002, and 66.7% vs. 0% for patients without EKG electrical activity, p < 0.001). The sensitivity of ultrasound cardiac motion to predict survival to hospital admission was 86% (specificity, 91%; positive predictive value, 30%; negative predictive value, 99%). When examined by mechanism, sensitivity was 100% for the 111 patients with penetrating trauma and 75% for the 50 patients with blunt trauma. CONCLUSION: Survival in pulseless traumatic arrest is very low, but survival for patients with no cardiac motion on ultrasound is also exceedingly rare. Cardiac ultrasound had a negative predictive value approaching 100% for survival to hospital admission. For patients with prolonged prehospital cardiopulmonary resuscitation, ultrasound evaluation of cardiac motion in pulseless patients with trauma may be a rapid way to help determine which patients have no chance of survival in the setting of lethal injuries, so that futile resuscitations can be stopped.