1
|
Urgent procedures or surgeries in patients receiving oral anticoagulants: a systematic literature review. J Thromb Thrombolysis 2023; 55:197-202. [PMID: 36462135 DOI: 10.1007/s11239-022-02739-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 12/05/2022]
Abstract
There are limited data about the frequency of urgent surgical emergencies among patients receiving oral anticoagulants (OACs). We conducted a systematic literature review of Medline and EMBASE for published English-language articles of adult patients receiving oral anticoagulant treatment (vitamin K antagonists, apixaban, dabigatran, edoxaban, rivaroxaban) that reported on patients experiencing unplanned emergent or urgent surgery/procedure or trauma. Randomized trials, observational studies, and case series (50-100 cases) were included. The primary outcome was the frequency of unplanned urgent surgery or invasive procedures among OAC-treated patients with a focus on those not precipitated by the presence of major bleeding. The protocol was not registered. Funding was provided by Covis Pharmaceuticals. The search yielded 1367 potential studies of which 34 were included in the final review. One study reported the rate of urgent surgery/procedures among a large cohort of patients treated with dabigatran or warfarin for atrial fibrillation (~ 1% per year). Another study reported the rate of bleeding or urgent surgery among OAC-treated patients experiencing a fracture or trauma (0.489% per patient-year). The remaining 32 studies were cohorts of OAC-treated patients who received reversal or hemostatic therapies for major bleeding or urgent surgery. A median of 28.8% of these patients underwent surgery or invasive procedure. Urgent surgery appears to be a common, yet understudied complication during OAC treatment potentially associated with high rates of adverse outcomes. With increased eligibility for OACs, future studies evaluating the management and outcomes in this setting are needed.
Collapse
|
2
|
Jay-Caillierez L, Friggeri A, Viste A, Lefevre M, Decullier E, Bernard L, Piriou V, David JS. Safety and efficacy of a strategy of vitamin K antagonist reversal with prothrombin complex concentrates compared to vitamin K in patients with hip fracture. Can J Surg 2021; 64:E330-E338. [PMID: 34085510 PMCID: PMC8327982 DOI: 10.1503/cjs.002120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Increased preoperative delay in patients with hip fractures may be responsible for increased morbidity and mortality. We hypothesized that a strategy of reversal of vitamin K antagonist (VKA) by prothrombin complexes concentrates (PCCs), as compared to vitamin K, is safe and reduces preoperative delay and hospital length of stay (LOS). Methods: In this pilot study, we reviewed the records of patients admitted to a university-affiliated hospital for hip fracture between Jan. 1, 2012, and Dec. 31, 2016, who were taking VKA. Patients were stratified according to reversal strategy (vitamin K v. PCC). Adverse effects, time to surgery, LOS and mortality were collected from the electronic medical record and were compared between the 2 study groups and a control group not treated with VKA. Results: A total of 141 patients were included in the study: 65 in the vitamin K group, 26 in the PCC group and 50 in the control group. The median preoperative delay in the PCC group (20 h [interquartile range (IQR)] 13–25 h]) and the control group (20 h [IQR 15–33 h]) was lower than that in the vitamin K group (45 h [IQR 31–52 h]) (p < 0.001). Patients in the PCC group had a shorter median hospital LOS than those in the vitamin K group (6 d [IQR 4–9 d] v. 8 d [IQR 6–11 d], p < 0.05). No difference was observed in the proportion of patients who received a red blood cell transfusion, or had thrombotic or hemorrhagic complications. No difference in mortality at 12 months was observed between the groups. Conclusion: In patients with hip fracture, the use of PCCs as compared to vitamin K to reverse the effect of VKA significantly reduced preoperative delay and hospital LOS, and was not associated with an increase in the rates of thrombotic or hemorrhagic complications. Prospective studies involving a greater number of patients are required to confirm these promising results.
Collapse
Affiliation(s)
- Lucille Jay-Caillierez
- From the Service d'Anesthésie Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Jay-Caillierez, Friggeri, Lefevre, Piriou, David); the Service Recherche et Epidémiologie Cliniques, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France (Decullier, Lorraine); the EA Santé Individu Société, Université Claude Bernard Lyon 1, Lyon, France (Decullier, Bernard); the Service de Chirurgie Orthopédique, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Viste); IFSTTAR, UMR-T9406, Laboratoire de Biomécanique et Mécanique des Chocs, Bron, France (Viste); and the Faculté de Médecine, Université Claude Bernard Lyon 1, Lyon, France (Friggeri, Viste, Piriou, David)
| | - Arnaud Friggeri
- From the Service d'Anesthésie Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Jay-Caillierez, Friggeri, Lefevre, Piriou, David); the Service Recherche et Epidémiologie Cliniques, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France (Decullier, Lorraine); the EA Santé Individu Société, Université Claude Bernard Lyon 1, Lyon, France (Decullier, Bernard); the Service de Chirurgie Orthopédique, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Viste); IFSTTAR, UMR-T9406, Laboratoire de Biomécanique et Mécanique des Chocs, Bron, France (Viste); and the Faculté de Médecine, Université Claude Bernard Lyon 1, Lyon, France (Friggeri, Viste, Piriou, David)
| | - Anthony Viste
- From the Service d'Anesthésie Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Jay-Caillierez, Friggeri, Lefevre, Piriou, David); the Service Recherche et Epidémiologie Cliniques, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France (Decullier, Lorraine); the EA Santé Individu Société, Université Claude Bernard Lyon 1, Lyon, France (Decullier, Bernard); the Service de Chirurgie Orthopédique, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Viste); IFSTTAR, UMR-T9406, Laboratoire de Biomécanique et Mécanique des Chocs, Bron, France (Viste); and the Faculté de Médecine, Université Claude Bernard Lyon 1, Lyon, France (Friggeri, Viste, Piriou, David)
| | - Mathilde Lefevre
- From the Service d'Anesthésie Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Jay-Caillierez, Friggeri, Lefevre, Piriou, David); the Service Recherche et Epidémiologie Cliniques, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France (Decullier, Lorraine); the EA Santé Individu Société, Université Claude Bernard Lyon 1, Lyon, France (Decullier, Bernard); the Service de Chirurgie Orthopédique, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Viste); IFSTTAR, UMR-T9406, Laboratoire de Biomécanique et Mécanique des Chocs, Bron, France (Viste); and the Faculté de Médecine, Université Claude Bernard Lyon 1, Lyon, France (Friggeri, Viste, Piriou, David)
| | - Evelyne Decullier
- From the Service d'Anesthésie Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Jay-Caillierez, Friggeri, Lefevre, Piriou, David); the Service Recherche et Epidémiologie Cliniques, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France (Decullier, Lorraine); the EA Santé Individu Société, Université Claude Bernard Lyon 1, Lyon, France (Decullier, Bernard); the Service de Chirurgie Orthopédique, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Viste); IFSTTAR, UMR-T9406, Laboratoire de Biomécanique et Mécanique des Chocs, Bron, France (Viste); and the Faculté de Médecine, Université Claude Bernard Lyon 1, Lyon, France (Friggeri, Viste, Piriou, David)
| | - Lorraine Bernard
- From the Service d'Anesthésie Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Jay-Caillierez, Friggeri, Lefevre, Piriou, David); the Service Recherche et Epidémiologie Cliniques, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France (Decullier, Lorraine); the EA Santé Individu Société, Université Claude Bernard Lyon 1, Lyon, France (Decullier, Bernard); the Service de Chirurgie Orthopédique, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Viste); IFSTTAR, UMR-T9406, Laboratoire de Biomécanique et Mécanique des Chocs, Bron, France (Viste); and the Faculté de Médecine, Université Claude Bernard Lyon 1, Lyon, France (Friggeri, Viste, Piriou, David)
| | - Vincent Piriou
- From the Service d'Anesthésie Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Jay-Caillierez, Friggeri, Lefevre, Piriou, David); the Service Recherche et Epidémiologie Cliniques, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France (Decullier, Lorraine); the EA Santé Individu Société, Université Claude Bernard Lyon 1, Lyon, France (Decullier, Bernard); the Service de Chirurgie Orthopédique, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Viste); IFSTTAR, UMR-T9406, Laboratoire de Biomécanique et Mécanique des Chocs, Bron, France (Viste); and the Faculté de Médecine, Université Claude Bernard Lyon 1, Lyon, France (Friggeri, Viste, Piriou, David)
| | - Jean-Stéphane David
- From the Service d'Anesthésie Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Jay-Caillierez, Friggeri, Lefevre, Piriou, David); the Service Recherche et Epidémiologie Cliniques, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France (Decullier, Lorraine); the EA Santé Individu Société, Université Claude Bernard Lyon 1, Lyon, France (Decullier, Bernard); the Service de Chirurgie Orthopédique, Hospices Civils de Lyon, Groupement Hospitalier Sud, Pierre Bénite, France (Viste); IFSTTAR, UMR-T9406, Laboratoire de Biomécanique et Mécanique des Chocs, Bron, France (Viste); and the Faculté de Médecine, Université Claude Bernard Lyon 1, Lyon, France (Friggeri, Viste, Piriou, David)
| |
Collapse
|
3
|
Meinig R, Cornutt D, Jarvis S, Salottolo K, Kelly M, Harrison P, Nentwig M, Morgan S, Nwafo N, McNair P, Banerjee R, Woods B, Bar-Or D. Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions. J Clin Orthop Trauma 2020; 14:45-51. [PMID: 33717896 PMCID: PMC7920139 DOI: 10.1016/j.jcot.2020.09.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Warfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear. METHODS This was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the "wait and watch" method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery. RESULTS There were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery. CONCLUSIONS Partial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs.
Collapse
Key Words
- AAOS, American Academy of Orthopedic Surgeons
- ANOVA, analysis of variance
- CVA, cerebrovascular accident
- DOAC, direct oral anticoagulants
- DVT, deep vein thrombosis
- FFP, fresh frozen plasma
- Geriatric
- HIPAA, health insurance accountability and assurance act
- HLOS, hospital length of stay
- Hip fracture
- ICD, international classification of diseases
- ICU LOS, intensive care unit length of stay
- INR, international normalized ratio
- ION, Injury Outcomes Network
- IQR, interquartile range
- IV, intravenous
- MI, myocardial infarction
- PCC, prothrombin complex concentrates
- PE, pulmonary embolism
- Reversal
- SD, standard deviation
- TQIP, Trauma Quality Improvement Program
- Trauma
- Warfarin
- aPCC, activated prothrombin complex concentrates
- mL, milliliters
- pRBC, packed red blood cells
Collapse
Affiliation(s)
- Richard Meinig
- Orthopedic Surgery and Trauma, Penrose Hospital, 1263 Lake Plaza Dr, Colorado Springs, CO, 80906, USA
| | - David Cornutt
- Emergency Medicine, Regional West Medical Center, 4021 Avenue B, Scottsbluff, NE, 69361, USA
| | - Stephanie Jarvis
- Injury Outcomes Network (ION) Research, 501 E. Hampden Ave, Englewood, CO, 80113, USA
| | - Kristin Salottolo
- Injury Outcomes Network (ION) Research, 501 E. Hampden Ave, Englewood, CO, 80113, USA
| | - Michael Kelly
- Orthopedic Surgery and Trauma, Penrose Hospital, 1263 Lake Plaza Dr, Colorado Springs, CO, 80906, USA
| | - Paul Harrison
- General, Trauma, & Orthopedic Surgery, Wesley Medical Center, 3242 E. Murdock Street, Wichita, KS, 67208, USA
| | - Michelle Nentwig
- General, Trauma, & Orthopedic Surgery, Wesley Medical Center, 3242 E. Murdock Street, Wichita, KS, 67208, USA
| | - Steven Morgan
- Orthopedic Surgery, Internal Medicine, Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA
| | - Nnamdi Nwafo
- Orthopedic Surgery, Internal Medicine, Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA
| | - Patrick McNair
- Orthopedic Sports Medicine and Trauma, St. Anthony Hospital, 11600 West 2nd Plaza, Lakewood, CO, 80228, USA
| | - Rahul Banerjee
- Orthopaedic Trauma, Medical City Plano, 1600 Coit Rd Suite 104, Plano, TX, 75075, USA
| | - Bradley Woods
- General Surgery, Research Medical Center, 2316 East Meyer Boulevard, Kansas City, MO, 64132, USA
| | - David Bar-Or
- Injury Outcomes Network (ION) Research, 501 E. Hampden Ave, Englewood, CO, 80113, USA
- Corresponding author. Injury Outcomes Network (ION) Research, 501 E Hampden Ave, Englewood, CO, 80113, USA.
| |
Collapse
|
4
|
Meinig R, Jarvis S, Orlando A, Nwafo N, Banerjee R, McNair P, Woods B, Harrison P, Nentwig M, Kelly M, Smith W, Bar-Or D. Is anticoagulation reversal necessary prior to surgical treatment of geriatric hip fractures? J Clin Orthop Trauma 2020; 11:S93-S99. [PMID: 31992926 PMCID: PMC6977537 DOI: 10.1016/j.jcot.2019.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Hip fracture surgery in geriatric patients on anticoagulants may increase the risk for blood loss. Anticoagulation reversal may lower these risks; however, data on blood loss and transfusions are limited. The study purpose was to compare outcomes between hip fracture patients 1) not on anticoagulants 2) whose anticoagulants were reversed, and 3) whose anticoagulants were not reversed. METHODS This four-year retrospective cohort study at six Level 1 Trauma Centers enrolled geriatric patients (≥65) with isolated hip fractures. The primary outcome was total hospital blood loss (ml). Secondary outcomes: hospital length of stay (HLOS) and volume of packed red blood cells (pRBC) transfusions (ml). Statistical analyses included: Fisher's, chi-squared, Kruskal-Wallis, linear mixed-effect and logistic regression. Bonferroni adjusted alpha = 0.025. RESULTS Of the 459 patients, 189 (41%) were not on anticoagulants, 186 (41%) were reversed, and 84 (18%) were not reversed. The LS mean (SE) blood loss was 134 ml (12) for not reversed patients and 159 (17) for reversed patients; no significant difference compared to those not on anticoagulants [138 (12)], p-diff = 0.14 and 0.83, respectively. The LS mean (SE) HLOS was significantly longer for the reversed patients, 7.7 (0.4) days, when compared to those not on anticoagulants, 6.8 (0.4), p = 0.02, and when compared to those not reversed, 6.3 (0.6), p = 0.01. There was no significant difference in pRBC transfusions. CONCLUSION Not reversing anticoagulants for geriatric hip fractures was not associated with increased volume of blood loss or transfusions when compared to those reversed. Delayed surgery for anticoagulant reversal may be unnecessary and contributing to an increased HLOS.
Collapse
Affiliation(s)
- Rick Meinig
- Orthopedic Trauma, Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO, 80907, USA
| | - Stephanie Jarvis
- Trauma Department, ION Research, 383 Corona St. #319, Denver, CO, 80218, USA
| | - Alessandro Orlando
- Trauma Department, ION Research, 383 Corona St. #319, Denver, CO, 80218, USA
| | - Nnamdi Nwafo
- Internal Medicine, Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA
| | - Rahul Banerjee
- Orthopedic Surgery, Medical City Plano, 3901 West 15th Street, Plano, TX, 75075, USA
| | - Patrick McNair
- Orthopedic Trauma, St. Anthony’s Hospital, 11600 West 2nd Place, Lakewood, CO, 80228, USA
| | - Bradley Woods
- Surgery Research Medical Center, 2316 East Meyer Blvd, Kansas City, MO, 64132, USA
| | - Paul Harrison
- Trauma Surgery, Wesley Medical Center, 550 N. Hillside St., Wichita, KS, 67214, USA
| | - Michelle Nentwig
- Orthopedic Surgery, Wesley Medical Center, 550 N. Hillside St., Wichita, KS, 67214, USA
| | - Michael Kelly
- Orthopedic Trauma, Penrose Hospital, 2222 North Nevada Ave., Colorado Springs, CO, 80907, USA
| | - Wade Smith
- Orthopedic Trauma, Swedish Medical Center, 501 E Hampden Ave., Englewood, CO, 80113, USA
| | - David Bar-Or
- Trauma Department, ION Research, 383 Corona St. #319, Denver, CO, 80218, USA
| |
Collapse
|
5
|
Agarwal P, Abdullah KG, Ramayya AG, Nayak NR, Lucas TH. A Retrospective Propensity Score-Matched Early Thromboembolic Event Analysis of Prothrombin Complex Concentrate vs Fresh Frozen Plasma for Warfarin Reversal Prior to Emergency Neurosurgical Procedures. Neurosurgery 2019; 82:877-886. [PMID: 29106685 DOI: 10.1093/neuros/nyx327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 05/16/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Reversal of therapeutic anticoagulation prior to emergency neurosurgical procedures is required in the setting of intracranial hemorrhage. Multifactor prothrombin complex concentrate (PCC) promises rapid efficacy but may increase the probability of thrombotic complications compared to fresh frozen plasma (FFP). OBJECTIVE To compare the rate of thrombotic complications in patients treated with PCC or FFP to reverse therapeutic anticoagulation prior to emergency neurosurgical procedures in the setting of intracranial hemorrhage at a level I trauma center. METHODS Sixty-three consecutive patients on warfarin therapy presenting with intracranial hemorrhage who received anticoagulation reversal prior to emergency neurosurgical procedures were retrospectively identified between 2007 and 2016. They were divided into 2 cohorts based on reversal agent, either PCC (n = 28) or FFP (n = 35). The thrombotic complications rates within 72 h of reversal were compared using the χ2 test. A multivariate propensity score matching analysis was used to limit the threat to interval validity from selection bias arising from differences in demographics, laboratory values, history, and clinical status. RESULTS Thrombotic complications were uncommon in this neurosurgical population, occurring in 1.59% (1/63) of treated patients. There was no significant difference in the thrombotic complication rate between groups, 3.57% (1/28; PCC group) vs 0% (0/35; FFP group). Propensity score matching analysis validated this finding after controlling for any selection bias. CONCLUSION In this limited sample, thrombotic complication rates were similar between use of PCC and FFP for anticoagulation reversal in the management of intracranial hemorrhage prior to emergency neurosurgical procedures.
Collapse
Affiliation(s)
- Prateek Agarwal
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kalil G Abdullah
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin G Ramayya
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil R Nayak
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy H Lucas
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
6
|
Prothrombin Complex Concentrates for Perioperative Vitamin K Antagonist and Non-vitamin K Anticoagulant Reversal. Anesthesiology 2019; 129:1171-1184. [PMID: 30157037 DOI: 10.1097/aln.0000000000002399] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Vitamin K antagonist therapy is associated with an increased bleeding risk, and clinicians often reverse anticoagulation in patients who require emergency surgical procedures. Current guidelines for rapid anticoagulation reversal for emergency surgery recommend four-factor prothrombin complex concentrate and vitamin K coadministration. The authors reviewed the current evidence on prothrombin complex concentrate treatment for vitamin K antagonist reversal in the perioperative setting, focusing on comparative studies and in the context of intracranial hemorrhage and cardiac surgery. The authors searched Cochrane Library and PubMed between January 2008 and December 2017 and retrieved 423 English-language papers, which they then screened for relevance to the perioperative setting; they identified 36 papers to include in this review. Prothrombin complex concentrate therapy was consistently shown to reduce international normalized ratio rapidly and control bleeding effectively. In comparative studies with plasma, prothrombin complex concentrate use was associated with a greater proportion of patients achieving target international normalized ratios rapidly, with improved hemostasis. No differences in thromboembolic event rates were seen between prothrombin complex concentrate and plasma, with prothrombin complex concentrate also demonstrating a lower risk of fluid overload events. Overall, the studies the authors reviewed support current recommendations favoring prothrombin complex concentrate therapy in patients requiring vitamin K antagonist reversal before emergency surgery.
Collapse
|
7
|
Sun GH, Patel V, Moreno-Duarte I, Zahedi F, Ursprung E, Couper G, Chen FY, Welsby IJ, Comenzo R, Kao G, Cobey FC. Intraoperative Administration of 4-Factor Prothrombin Complex Concentrate Reduces Blood Requirements in Cardiac Transplantation. J Cardiothorac Vasc Anesth 2018; 32:161-167. [DOI: 10.1053/j.jvca.2017.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Indexed: 11/11/2022]
|
8
|
Faraoni D, Koster A. Use of prothrombin complex concentrate containing heparin for emergency reversal of bivalirudin anticoagulation: a word of caution. Perfusion 2017; 33:241-242. [PMID: 29064332 DOI: 10.1177/0267659117737832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David Faraoni
- 1 Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Andreas Koster
- 2 Institute of Anaesthesiology, Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen, Ruhr-University Bochum, Germany
| |
Collapse
|
9
|
Abstract
An understanding of how to counteract the anticoagulant effect of direct oral anticoagulants is essential in the event of haemorrhage, emergency surgery and overdose. This review summarizes strategies for the reversal of direct oral anticoagulants, including the use of novel agents.
Collapse
Affiliation(s)
- X-Y Zhang
- Haematology Specialist Registrar, Department of Haematology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - M J Desborough
- Clinical Research Fellow, NHS Blood and Transplant, John Radcliffe Hospital, Oxford, and Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford
| | - S Shapiro
- Consultant Haematologist, Oxford Haemophilia and Thrombosis Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE
| |
Collapse
|
10
|
Silvetti S, Crivellari M, Castiglioni A, Landoni G, Zangrillo A, Alfieri O, Koster A, Faraoni D, Bolliger D, Tanaka KA. CASE 12—2016 Ascending Aorta Dissection in a Jehovah’s Witness Patient on Warfarin. J Cardiothorac Vasc Anesth 2016; 30:1709-1715. [DOI: 10.1053/j.jvca.2016.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Indexed: 01/01/2023]
|
11
|
Abstract
BACKGROUND Recently, a new generation of direct-acting oral anticoagulants (DOACs) with a greater specificity towards activated coagulation factors was introduced based on encouraging results for efficacy and safety in clinical studies. An initial limitation of these new drugs was the absence of an adequate strategy to reverse the effect if a bleeding event occurs or an urgent invasive procedure has to be carried out. MAIN TEXT Specific reversing agents for DOACs have become available, however, and are now evaluated in clinical studies. For the anti-factor Xa agents (rivaroxaban, apixaban, and edoxaban) a number of studies have shown that the administration of prothrombin complex concentrate resulted in a correction of the prolonged prothrombin time and restored depressed thrombin generation after rivaroxaban treatment in a controlled trial in healthy human subjects. In view of the relatively wide availability of prothrombin complex concentrates, this would be an interesting option if the results can be confirmed in patients on oral factor Xa inhibitors who present with bleeding complications. More specific reversal can be achieved with andexanet, a new agent currently in development that competitively binds to the anti-factor Xa agents. For the direct thrombin inhibitor dabigatran, the administration of prothrombin complex concentrates showed variable results in various volunteer trials and efficacy at relatively high doses in animal studies. Recently, a Fab fragment of a monoclonal antibody (idarucizumab) was shown to be an effective reversal agent for dabigatran in human studies. CONCLUSION For the new generation of DOACs, several reversal strategies and specific antidotes are under evaluation, although most interventions need further evaluation in clinical trials.
Collapse
Affiliation(s)
- Marcel Levi
- Department of Vascular Medicine, Academic Medical Center (E-2), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Department of Medicine, University of Amsterdam, Amsterdam, The Netherlands.
| |
Collapse
|
12
|
Bucko A, Makris M. Pre-operative PCC for non-bleeding patients on warfarin. Thromb Res 2016; 139:158-9. [DOI: 10.1016/j.thromres.2015.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/19/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
|