Platelet aggregometry for hip fracture surgery in patients treated with clopidogrel: a pilot study.

Surgery for hip fractures should be performed within 48 h from patient's admission. However, several factors including chronic antiplatelet therapy could delay operation. Among the totality of patients taking clopidogrel, up to 30% are resistant to the drug and have a normal platelets reactivity. We propose thromboelastography (TEG) with an ADP Platelet Mapping assay kit to assess platelet aggregation, a safe tool that could help to avoid surgery delay in those patients treated with antiplatelet therapy. A patient's blood sample was collected for aggregometry. If MA-ADP and platelets aggregation (%) were within normal values, the patient was fit for immediate surgery with neuraxial anesthesia and ultrasound-guided nerve block. If one of the two parameters or both were deranged, a mortality risk assessment was estimated. In the low risk category, the patients waited till normalization of the parameters, whereas in the high-risk group a general anesthesia and peripheral antalgic block was carried out. Nine patients were enrolled. Four of them showed normal aggregometry and surgery was performed within 24 h from admission. Two patients were classified as high mortality risk and surgery was carried out under general anesthesia. Three patients awaited operation till normalization of parameters. No peri or post-operative complications were reported. An aggregometry-guided protocol can safely expedite hip fracture surgery in patients taking clopidogrel. Nonetheless, in presence of a normal platelets function, clinician can opt for a neuraxial instead of general anesthesia reducing the incidence of postoperative delirium and cognitive dysfunction.Trial registration: prospectively registered at clinicaltrials.gov (NCT04642209; date of registration: 23rd November 2020).

Case Report: Canakinumab for the Treatment of a Patient With COVID-19 Acute Respiratory Distress Syndrome.

Severe cases of COVID-19 present with serious lung inflammation, acute respiratory distress syndrome and multiorgan damage. SARS-CoV-2 infection is associated with high cytokine levels, including interleukin-6 and certain subsets of immune cells, in particular, NK, distinguished according to the cell surface density of CD56. Cytokine levels are inversely correlated with lymphocyte count, therefore cytokine release syndrome may be an impediment to the adaptive immune response against SARS-CoV-2 infection. Canakinumab, a monoclonal antibody targeting IL-1ß is under investigation for the treatment of severe SAR-CoV-2 infection. An 85 year old male presenting in our hospital with COVID-19, whose condition was complicated by acute respiratory distress syndrome and cardiac and renal failure (with oliguria) after 25 days of hospitalization, was intubated and received canakinumab for compassionate use. On the next day, diuresis recovered and conditions improved: high IL-6 levels and NK cells expressing CD56 bright (associated with cytokine relase) were significantly reduced giving rise to NK CD56 dim . Patient died on day 58 with pulmonary bacterial superinfection and persistent SARS-CoV-2 positivity. In conclusion, canakinumab rescued a high risk, very elderly patient, from multiorgan damage complicating COVID-19. It may represent an useful treatment in severe cases.