Anesthesia Clinical Trial
Official title:
Platelet Aggregometry to Drive the Surgical Timing in Elderlies With Hip Fracture and Receiving Clopidogrel.
In elderly patients, hip fracture should be surgically treated within 48 hours from admission, since its deferral worsens the mortality. However, sometimes patients are affected by cardiovascular or cerebral comorbidities, deeming necessary the use of antiplatelets and/or anticoagulant therapies. Clopidogrel is a second-generation thienopyridine antiplatelet drug which exerts its effect by the inhibition of the platelet's purinergic receptor P2Y12 preventing adenosine diphosphate (ADP) from stimulating it. Guidelines recommend to withhold clopidogrel for 5 days before the possibility to perform neuraxial anesthesia, which is frequently the optimal perioperative management of a fragile patient. It should be mentioned however that around 30% of patients are resistant to clopidogrel and they show a normal platelet reactivity despite the antiplatelet therapy. Therefore, in principle, these patients do not require to defer surgery. We have therefore hypothesized that some patients taking clopidogrel might anticipate surgery before 5 days and within 48 hours, following a protocol based on the assessment of coagulation and platelet aggregation through thromboelastography (TEG) in combination with an ADP Platelet Mapping assay kit. After hospital admission for femur fracture, eligible patients would be evaluated by the anesthesiologist and the orthopedic physicians for anesthesia and surgery. Immediately a sample of blood should be collected for TEG with ADP Platelet Mapping test. If both MA-ADP and platelets aggregation (%) will be within normal values, the patient could be considered as candidate for immediate surgery (within 48 hours) with neuraxial anesthesia and ultrasound-guided antalgic femoral nerve block. If MA-ADP and/or platelets aggregation (%) are lower, risk for mortality should be assessed. If the patient would be considered at high risk for mortality, he/she would undergo to general anesthesia and peripheral antalgic block to not postpone surgery. Otherwise, surgery would be postponed until the normalization of both MA-ADP and platelet aggregation.
Status | Not yet recruiting |
Enrollment | 9 |
Est. completion date | December 30, 2020 |
Est. primary completion date | December 15, 2020 |
Accepts healthy volunteers | No |
Gender | All |
Age group | 65 Years and older |
Eligibility | Inclusion Criteria: - all patients older than 65 years/old - admission to the hospital for suspected traumatic femur fracture - home therapy with clopidogrel 75 mg/die at home Exclusion Criteria: - pre-existing coagulopathies - assumption of any anticoagulant oral therapy - platelet count <100.000 mcL - pre-existing liver disease - known autoimmune diseases - presence of hematological malignancies |
Country | Name | City | State |
---|---|---|---|
Italy | Federico Longhini | Catanzaro |
Lead Sponsor | Collaborator |
---|---|
University Magna Graecia |
Italy,
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Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, De Hert S, Ford I, Gonzalez Juanatey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Luescher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Uva MS, Voudris V, Funck-Brentano C; Authors/Task Force Members. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol. 2014 Oct;31(10):517-73. doi: 10.1097/EJA.0000000000000150. Review. — View Citation
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Tarrant SM, Kim RG, McGregor KL, Palazzi K, Attia J, Balogh ZJ. Dual Antiplatelet Therapy and Surgical Timing in Geriatric Hip Fracture. J Orthop Trauma. 2020 Oct;34(10):559-565. doi: 10.1097/BOT.0000000000001779. — View Citation
Warlo EMK, Arnesen H, Seljeflot I. A brief review on resistance to P2Y(12) receptor antagonism in coronary artery disease. Thromb J. 2019 May 20;17:11. doi: 10.1186/s12959-019-0197-5. eCollection 2019. Review. — View Citation
Yang Z, Ni J, Long Z, Kuang L, Gao Y, Tao S. Is hip fracture surgery safe for patients on antiplatelet drugs and is it necessary to delay surgery? A systematic review and meta-analysis. J Orthop Surg Res. 2020 Mar 12;15(1):105. doi: 10.1186/s13018-020-01624-7. — View Citation
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Primary | Patients undergoing to hip replacement surgery | Number of patients undergoing to hip replacement surgery within 48 hours from hospital admission | within 48 hours from hospital admission | |
Secondary | Occurrence of peri or post-operative complications | Occurrence of peri or post-operative complications, such as postoperative myocardial infarction, thromboembolism, and postoperative confusion | 28 days from admission | |
Secondary | Occurrence of intra-operative hypotension | Reduction of mean arterial pressure by 10% from baseline | During surgery | |
Secondary | Presence of post-operative bleeding | Presence of post-operative bleeding greater than 600 ml, considered as clinically relevant | Within 48 hours after surgery |
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