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1.
J Surg Res ; 260: 369-376, 2021 04.
Article in English | MEDLINE | ID: mdl-33388533

ABSTRACT

BACKGROUND: Patients on warfarin with traumatic intracranial hemorrhage often have the warfarin effects pharmacologically reversed. We compared outcomes among patients who received 4-factor prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), or no reversal to assess the real-world impact of PCC on elderly patients with traumatic intracranial hemorrhage (ICH). MATERIALS AND METHODS: This was a retrospective analysis of 150 patients on preinjury warfarin. Data were manually abstracted from the electronic medical record of an academic level 1 trauma center for patients admitted between January 2013 and December 2018. Outcomes were ICH progression on follow-up computed tomography scan, mortality, need for surgical intervention, and trends in the use of reversal agents. RESULTS: Of 150 patients eligible for analysis, 41 received FFP, 60 PCC, and 49 were not reversed. On multivariable analysis, patients not reversed [OR 0.25 95% CI (0.31-0.85)] and women [OR 0.38 95% CI (0.17-0.88)] were less likely to experience progression of their initial bleed on follow-up computed tomography while subdural hemorrhage increased the risk [OR 3.69 95% CI (1.27-10.73)]. There was no difference between groups in terms of mortality or need for surgery. Over time use of reversal with PCC increased while use of FFP and not reversing warfarin declined (P < 0.001). CONCLUSIONS: Male gender and using a reversal agent were associated with progression of ICH. Choice of reversal did not impact the need for surgery, hospital length of stay, or mortality. Some ICH patients may not require warfarin reversal and may bias studies, especially retrospective studies of warfarin reversal.


Subject(s)
Anticoagulants/adverse effects , Blood Coagulation Factors/therapeutic use , Coagulants/therapeutic use , Intracranial Hemorrhage, Traumatic/therapy , Plasma , Practice Patterns, Physicians'/trends , Warfarin/adverse effects , Aged , Aged, 80 and over , Blood Coagulation Factors/economics , Coagulants/economics , Connecticut , Female , Follow-Up Studies , Hospital Costs/statistics & numerical data , Humans , Intracranial Hemorrhage, Traumatic/diagnostic imaging , Intracranial Hemorrhage, Traumatic/economics , Intracranial Hemorrhage, Traumatic/mortality , Linear Models , Logistic Models , Male , Multivariate Analysis , Practice Patterns, Physicians'/economics , Retrospective Studies , Tomography, X-Ray Computed , Trauma Centers/economics , Treatment Outcome
2.
Ann Vasc Surg ; 73: 336-343, 2021 May.
Article in English | MEDLINE | ID: mdl-33373769

ABSTRACT

BACKGROUND: The choice of anesthetic for carotid endarterectomy (CEA) continues to be controversial. Recent literature suggests improved outcomes with the use of regional anesthesia (RA) compared with general anesthesia (GA). The objective of this study was to examine the utilization and outcomes of RA for CEA using a national database. METHODS: The targeted CEA files of the American College of Surgeons' National Surgical Quality Improvement Program (2011-2017) were reviewed. Patients were stratified based on anesthesia type into RA and GA, and patients' characteristics were compared between the 2 groups. The outcomes of CEA under GA and RA were compared after 2:1 propensity matching. RESULTS: There were 26,206 CEAs, and 14% (n = 3,664) were performed under RA, with no change in relative utilization during the study period (P = 0.557). Patients treated under RA were more likely to be older than 65 years (80.6% vs. 75.8%; P < 0.001) and White (90.8% vs. 83.5%; P < 0.001) but less likely to have diabetes (28.2% vs. 31.2%; P = 0.001), chronic obstructive pulmonary disease (10.2% vs. 10.5%; P < 0.001), and heart failure (1.0% vs. 1.5%; P = 0.02) and be symptomatic (37.4% vs. 42.7%; P < 0.001). After matching, there was no significant difference in baseline characteristics between the 2 groups. Patients undergoing RA were less likely to experience the combined end point of stroke, myocardial infarction, or mortality compared with GA. GA patients were more likely to have longer operating time and hospital length of stay. CONCLUSIONS: CEA performed under RA is associated with improved outcomes compared with GA. RA is underutilized in carotid surgery, and strategies to optimize its use are needed.


Subject(s)
Anesthesia, Conduction/trends , Anesthesia, General/trends , Carotid Artery Diseases/surgery , Endarterectomy, Carotid/trends , Practice Patterns, Physicians'/trends , Aged , Aged, 80 and over , Anesthesia, Conduction/adverse effects , Anesthesia, Conduction/mortality , Anesthesia, General/adverse effects , Anesthesia, General/mortality , Carotid Artery Diseases/mortality , Databases, Factual , Endarterectomy, Carotid/adverse effects , Endarterectomy, Carotid/mortality , Female , Humans , Male , Middle Aged , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , United States
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