术前低剂量阿司匹林的应用对创伤性颅内出血老年患者急诊神经外科术后结局的影响
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Preoperative Low-Dose Aspirin Exposure and Outcomes After Emergency Neurosurgery for Traumatic Intracranial Hemorrhage in Elderly Patients.
背景与目的
择期神经外科术前通常需停用抗血小板药物的使用，但这并不适用于急诊神经外科手术。本回顾性队列研究观察了老年急诊神经外科手术术前使用阿司匹林是否与恶化的术后结局有关。
方 法
本研究纳入了2008年-2012年期间一级创伤中心中所有因创伤性颅内出血行急诊神经外科手术的病例。并收集了年龄＞65岁术前使用阿司匹林的患者的人口统计学资料，合并症以及术后结局，其中排除标准是（1）多发伤，（2）术前除阿司匹林外联合使用了其它的抗凝药物或抗血小板药物，（3）合并了硬膜下或硬膜外或脑实质出血，以及（4）一次住院期间行两次神经外科手术者。主要结局指标是围术期失血量，术后因颅内出血需再次手术情况，住院期间的死亡情况，ICU停留时间和住院时间以及术前48h至术后48h期间输注血液制品的情况。此外，本研究还观察了血小板的输注是否能影响术前使用阿司匹林患者行急诊神经外科术后的结局。
结 果
本回顾性的队列研究共纳入171例患者，术前服用阿司匹林的老年患者（n=87,95%服用81mg/d）与未服用者年龄无统计学差异（n=84;78.3±7.8 vs 75.9±7.9岁，P＞0.05），但与术前未服用阿司匹林者相比，服用者的格拉斯哥昏迷评分分数较高一些（12.8±3.4 vs11.4±4，p=0.02）且大多合并有冠张动脉疾病（P＜0.05）。校正格拉斯哥昏迷评分和冠张动脉疾病后（校正比值比9.89,95%置信区间4.24-26.25），术前服用阿司匹林的老年患者围术期需输注血小板的概率更大。其它方面相关指标两组患者并无差异，且术前或术中血小板的输注并不能改善术前服用阿司匹林的老年患者术后的结局。
结 论
年龄＞65岁的创伤性颅内出血急诊神经外科患者术前低剂量阿司匹林的使用并不增加其围术期的出血量，住院时间以及住院死亡率。
原始文献摘要
Lee A T, Gagnidze A, Pan S R, et al. Preoperative Low-Dose Aspirin Exposure and Outcomes After Emergency Neurosurgery for Traumatic Intracranial Hemorrhage in Elderly Patients.[J]. Anesthesia and analgesia, 2017,125(2):514-520.10.1213/ANE.0000000000002053
BACKGROUND: Antiplatelet medications are usually discontinued before elective neurosurgery, but this is not an option for emergent neurosurgery. We performed a retrospective cohort study to examine whether preoperative aspirin use was associated with worse outcomes after emergency neurosurgery in elderly patients.
METHODS: We analyzed all cases of emergency neurosurgical procedures for traumatic intracranial hemorrhage from 2008 to 2012 at a level 1 trauma center. Demographics, comorbidities, and outcomes were compared for patients >/=65 years by preoperative aspirin exposure. Exclusion criteria were: (1) polytrauma, (2) concomitant use of other preoperative anticoagulants or antiplatelet agents, (3) surgical indication other than subdural, extradural, or intraparenchymal hemorrhage, and (4) repeat neurosurgical procedures within a single admission. Estimated intraoperative blood loss, postprocedural intracranial bleeding requiring reoperation, death in hospital, intensive care unit, and hospital lengths of stay and perioperative blood product transfusion from 48 hours before 48 hours after surgery were the study outcomes. We also examined whether platelet transfusion had an impact on outcomes for patients on aspirin.
RESULTS: The cohort included 171 patients. Patients receiving preoperative aspirin (n = 87, 95% taking 81 mg/day) were the same age as patients not receiving aspirin (n = 84; 78.3 +/- 7.8 vs 75.9 +/- 7.9 years, P > .05), had slightly higher admission Glasgow Coma Scale scores (12.8 +/- 3.4 vs 11.4 +/- 4, P = .02) and tended to have more coronary artery disease (P< .05). Adjusted for Glasgow Coma Scale and coronary artery disease, patients receiving preoperative aspirin had a higher odds of perioperative platelet transfusion (adjusted odds ratio 9.89, 95% confidence interval, 4.24-26.25). There were no other differences in outcomes between the 2 groups. Preoperative or intraoperative platelet transfusion was not associated with better outcomes among aspirin patients.
CONCLUSIONS: In patients age >/=65 years undergoing emergency neurosurgery for traumatic intracranial hemorrhage, preoperative low-dose aspirin treatment was not associated with increased perioperative bleeding, hospital lengths of stay, or in-hospital mortality.
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