背景:老年髋部骨折患者接受氯吡格雷是一项手术挑战。在中国,这些患者中的大多数在停用氯吡格雷至少5~7天后接受延迟手术治疗.然而,延迟手术与老年人的并发症和死亡率增加相关.这项回顾性平行比较研究调查了在停用氯吡格雷后5天内对老年髋部骨折患者进行早期手术的安全性。
方法:对2016年11月至2018年4月在北京积水潭医院骨科联合病房住院的65岁以上急性髋部骨折患者进行回顾性分析。60例伤前服用氯吡格雷和手术前<5天停药的患者构成氯吡格雷组。对照组60例未服用抗血小板或抗凝药物,与氯吡格雷组1:1性别匹配,骨折类型,手术程序,受伤至手术时间(±10h)。主要结局是围手术期失血,次要结局是输血需求,并发症,和死亡率。连续变量采用Studentt检验或Wilcoxon符号秩和检验,分类变量采用卡方检验。
结果:年龄,身体质量指数,美国麻醉医师协会评分,两组之间进行全身麻醉的百分比具有可比性(P>0.050)。冠心病患者的百分比(61.7%vs.18.3%;P<0.001)和脑血管疾病(45.0%vs.15.0%;P<0.010)明显高于氯吡格雷。控制组,分别。术前停用氯吡格雷的中位时间为73.0(范围:3.0~120.0)h。氯吡格雷组(中位:745mL)与对照组(中位:772mL)的围手术期失血量差异无统计学意义(P=0.866)。氯吡格雷组术中输血率(22/60,36.7%)高于对照组(12/60,20.0%)(P<0.050)。然而,整个围手术期输血率无显著差异(26/60,43.3%vs.20/60,33.3%;氯吡格雷组与对照组,分别为;P>0.050)。围手术期并发症无显著差异,以及两组之间30天和1年的死亡率。
结论:对于停用氯吡格雷5天内的老年患者,早期髋部骨折手术是安全的,没有增加围手术期失血,输血要求,并发症,与未服用抗血小板药物的患者相比,死亡率。
BACKGROUND: Geriatric hip fracture patients receiving clopidogrel are a surgical challenge. In China, most of these patients undergo delayed surgical treatment after clopidogrel withdrawal for at least 5 to 7 days. However, delayed surgery is associated with increased complications and mortality in the older adults. This retrospective paralleled comparison study investigated the safety of early surgery for geriatric hip fracture patients within 5 days of clopidogrel withdrawal.
METHODS: Acute hip fracture patients (≥65 years) who were hospitalized in the orthogeriatric co-management ward of Beijing Jishuitan Hospital between November 2016 and April 2018 were retrospectively reviewed. Sixty patients taking clopidogrel before injury and discontinued <5 days before surgery constituted the clopidogrel group. The control group constituted 60 patients not taking antiplatelet or anticoagulant drugs and matched 1:1 with the clopidogrel group for sex, fracture type, operative procedure, and time from injury to operation (±10 h). The primary outcome was perioperative blood loss and the secondary outcomes were transfusion requirement, complications, and mortality. The Student\'s t test or Wilcoxon signed rank sum test was used for continuous variables and the Chi-square test was used for categorical variables.
RESULTS: Age, body mass index, American Society of Anesthesiologists score, and percentage undergoing general anesthesia were comparable between the groups (P > 0.050). The percentages of patients with coronary heart disease (61.7% vs. 18.3%; P < 0.001) and cerebrovascular disease (45.0% vs. 15.0%; P < 0.010) were significantly higher in the clopidogrel vs. control groups, respectively. The median clopidogrel discontinuation time before operation was 73.0 (range: 3.0-120.0) h. There was no significant difference in the estimated perioperative blood loss between the clopidogrel group (median: 745 mL) and control group (median: 772 mL) (P = 0.866). The intra-operative transfusion rate was higher in the clopidogrel group (22/60, 36.7%) than that in the control group (12/60, 20.0%) (P < 0.050). However, there was no significant difference in the blood transfusion rate during the entire perioperative period (26/60, 43.3% vs. 20/60, 33.3%; clopidogrel group vs. control group, respectively; P > 0.050). There was no significant difference in perioperative complications, and 30-day and 1-year mortality rates between the groups.
CONCLUSIONS: Early hip fracture surgery is safe for elderly patients within 5 days of clopidogrel withdrawal, without increased perioperative blood loss, transfusion requirement, complications, and mortality compared with patients not taking antiplatelet drugs.