Practice Considerations of Early Aspirin Administration following Coronary Artery Bypass Surgery
AbstractThrombotic occlusion of saphenous vein grafts (SVG), the conduits most commonly used in coronary artery bypass grafting (CABG) surgery, causes significant morbidity and mortality. There is class 1A evidence that early aspirin administration following CABG reduces thrombotic SVG occlusion, as well as overall morbidity and mortality. The American Heart Association/American College of Cardiology and the European Association of Cardiothoracic Surgeons have issued guidelines recommending that 150 to 325 mg aspirin be administered within 6 hours following CABG. We carried out a clinical audit of our practice to identify any reasons for deviation from these standards of care and to implement any corrective measures. We prospectively collected data on 200 consecutive patients who underwent CABG to assess both the compliance in prescribing and administering aspirin and the effect on blood loss and transfusion requirements. Sixty-nine percent of patients received an aspirin loading dose 6 hours postoperatively. The reasons for nonadministration of aspirin were postoperative bleeding (10%), lack of a prescription despite aspirin being clinically indicated (13%), and a prescription for aspirin but no administration (9%). Reasons included inadequate handover between clinical teams (4%), aspirin loading ?24 hours preoperatively (2%), and administration after the first 6 hours (3%). Our audit showed that early aspirin administration did not cause further bleeding or increase blood or blood product transfusion. We followed the recommendations in the majority of cases, but there is scope for improvement in this practice and a need to address "gray areas" not covered by the guidelines.
Casati V, Gerli C, Franco A, et al. 2001. Activation of coagulation and fibrinolysis during coronary surgery: on-pump versus off-pump techniques. Anesthesiology 95:1103-9.nDunning J, Versteegh M, Fabbri A, et al. 2008. Guideline on antiplatelet and anticoagulation management in cardiac surgery. Eur J Cardiothorac Surg 34:73-92.nEagle KA, Guyton RA, Davidoff R, et al. 2004. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 110:e340-437.nFremes SE, Levinton C, Naylor CD, Chen E, Christakis GT, Goldman BS. 1993. Optimal antithrombotic therapy following aortocoronary bypass: a meta-analysis. Eur J Cardiothorac Surg 7:169-80.nGavaghan TP, Gebski V, Baron DW. 1991. Immediate postoperative aspirin improves vein graft patency early and late after coronary artery bypass graft surgery. A placebo-controlled, randomized study. Circulation 83:1526-33.nGoldman S, Copeland J, Moritz T, et al. 1988. Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study. Circulation 77:1324-32.nHata M, Sezai A, Niino T, et al. 2007. What is the optimal management for preventing saphenous vein graft diseases?: early results of intravascular angioscopic assessment. Circ J 71:286-7.nMangano DT. 2002. Aspirin and mortality from coronary bypass surgery. N Engl J Med 347:1309-17.nMusleh G, Dunning J. 2003. Does aspirin 6 h after coronary artery bypass grafting optimise graft patency? Interact Cardiovasc Thorac Surg 2:413-5.nSenior K. 2009. WHO Surgical Safety Checklist has value worldwide. Lancet Infect Dis 9:211.nShukla N, Angelini GD, Ascione R, Talpahewa S, Capoun R, Jeremy JY. 2003. Nitric oxide donating aspirins: novel drugs for the treatment of saphenous vein graft failure. Ann Thorac Surg 75:1437-42.nStein PD, Schunemann HJ, Dalen JE, et al. 2004. Antithrombotic therapy in patients with saphenous vein and internal mammary artery bypass grafts: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126(suppl):600S-8S.n
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