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Arimoto J, Ohata K, Tachikawa J, Goto S, Hayashi A, Ebisawa Y, Kobayashi M, Okada N, Kuwabara H, Nakaoka M, Sakai E, Kano Y, Minato Y, Kuriyama H, Chiba H. The Management of Direct Oral Anticoagulants for Colorectal Endoscopic Submucosal Dissection: A Multicenter Observational Study. Dig Dis Sci 2024; 69:933-939. [PMID: 38340260 DOI: 10.1007/s10620-024-08316-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND There is a lack of reports on the use of direct oral anticoagulants (DOACs) during colorectal endoscopic submucosal dissection (ESD). AIMS We aimed to assess whether the use of DOACs is associated with a higher incidence of delayed bleeding (DB) after ESD. METHODS A total of 4175 colorectal neoplasms in 3515 patients were dissected at our hospitals during study period. We included 3909 lesions in the final analysis. The lesions were divided into two groups: the no-AT group (3668 neoplasms) and the DOAC group (241 neoplasms). We also compared the DOAC withdrawal group (154 neoplasms) and the DOAC continuation group (87 neoplasms). RESULTS Among the 3909 lesions, DB occurred in a total of 90 cases (2.3%). The rate of DB was 2.2% (82/3668), and 3.3% (8/241), respectively. There were no significant differences in the rate of DB between the no-AT group and the DOAC group. In the DOAC group, there were no significant differences in the rate of DB between the withdrawal group (5.2%, 8/154) and the continuation group (0%, 0/87). The multivariable analysis identified the location of the lesion in the rectum (odds ratio [OR], 4.04; 95% confidence interval [CI], 2.614-6.242; p < 0.001) and lesions ≥ 30 mm in diameter (OR, 4.14; 95% CI, 2.349-7.34; p < 0.001) as independent risk factors for DB. CONCLUSIONS Our findings suggest that DOAC use has no significant important on the rate of DB. Prospective studies are warranted to determine whether treatment with DOACs should be interrupted prior to colorectal ESD.
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Affiliation(s)
- Jun Arimoto
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Ken Ohata
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Jun Tachikawa
- Department of Gastroenterology, Hiratsuka City Hospital, Hiratsuka, Kanagawa, Japan
| | - Shungo Goto
- Department of Gastroenterology, Chigasaki Municipal Hospital, Chigasaki, Kanagawa, Japan
| | - Akimichi Hayashi
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Yu Ebisawa
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Mikio Kobayashi
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Naoya Okada
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
- Department of Gastroenterology, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Hiroki Kuwabara
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Michiko Nakaoka
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan
| | - Eiji Sakai
- Department of Gastroenterology, Yokohama Sakae Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Yuki Kano
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yohei Minato
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Hitoshi Kuriyama
- Department of Gastroenterology, Chigasaki Municipal Hospital, Chigasaki, Kanagawa, Japan
| | - Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, 4-30-1, Chuo, Tokyo, Ota-Ku, 143-8527, Japan.
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Additional comments on the 2022 Joint ESAIC/ESRA guidelines: regional anaesthesia in patients on antithrombotic drugs. Eur J Anaesthesiol 2023; 40:68-70. [PMID: 36479995 DOI: 10.1097/eja.0000000000001732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
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Eliasberg CD, Levack AE, Gausden EB, Garvin S, Russell LA, Kelly AM. Perioperative Use of Novel Oral Anticoagulants in Orthopaedic Surgery: A Critical Analysis Review. JBJS Rev 2020; 7:e4. [PMID: 31291203 DOI: 10.2106/jbjs.rvw.18.00148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Claire D Eliasberg
- Departments of Orthopaedic Surgery (C.D.E., A.E.L., E.B.G., and A.M.K.), Anesthesiology (S.G.), and Medicine (L.A.R.), Hospital for Special Surgery, New York, NY
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Fonseca NM, Pontes JPJ, Perez MV, Alves RR, Fonseca GG. [SBA 2020: Regional anesthesia guideline for using anticoagulants update]. Rev Bras Anestesiol 2020; 70:364-387. [PMID: 32660771 DOI: 10.1016/j.bjan.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/10/2020] [Accepted: 02/21/2020] [Indexed: 10/24/2022] Open
Abstract
The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology (SBA) 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative revision, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.
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Affiliation(s)
- Neuber Martins Fonseca
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Disciplina de Anestesiologia, Uberlândia, MG, Brasil; Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Centro de Ensino e Treinamento (CET), Uberlândia, MG, Brasil; Comissão de Normas Técnicas da Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil.
| | - João Paulo Jordão Pontes
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; European Diploma in Anaesthesiology and Intensive Care, European Society of Anaesthesiology, Bruxelas, Bélgica
| | - Marcelo Vaz Perez
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Conselho Editorial da Revista Brasileira de Anestesiologia, São Paulo, SP, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Rodrigo Rodrigues Alves
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Gabriel Gondim Fonseca
- Irmandade da Santa Casa de Misericórdia de São Paulo, Anesthesiology Specialization, São Paulo, SP, Brasil
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Fonseca NM, Pontes JPJ, Perez MV, Alves RR, Fonseca GG. SBA 2020: Regional anesthesia guideline for using anticoagulants update. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32660771 PMCID: PMC9373103 DOI: 10.1016/j.bjane.2020.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Neuber Martins Fonseca
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Disciplina de Anestesiologia, Uberlândia, MG, Brasil; Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Centro de Ensino e Treinamento (CET), Uberlândia, MG, Brasil; Comissão de Normas Técnicas da Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil.
| | - João Paulo Jordão Pontes
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; European Diploma in Anaesthesiology and Intensive Care, European Society of Anaesthesiology, Bruxelas, Bélgica
| | - Marcelo Vaz Perez
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Conselho Editorial da Revista Brasileira de Anestesiologia, São Paulo, SP, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Rodrigo Rodrigues Alves
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Gabriel Gondim Fonseca
- Irmandade da Santa Casa de Misericórdia de São Paulo, Anesthesiology Specialization, São Paulo, SP, Brasil
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Weng XS, Liu J, Wu D. Chinese Survey on Enhanced Recovery after Surgery and Thromboprophylaxis Following Arthroplasty. Orthop Surg 2020; 12:900-906. [PMID: 32489003 PMCID: PMC7307227 DOI: 10.1111/os.12705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/13/2020] [Accepted: 04/25/2020] [Indexed: 12/28/2022] Open
Abstract
Objective To examine the current perspectives of enhanced recovery after surgery (ERAS) and the clinical practice applications of important ERAS principles among Chinese orthopaedic surgeons. Methods This was a cross‐sectional study using an online survey that was completed between November and December 2018. A 16‐item online questionnaire regarding the experiences of ERAS, perceptions of methods, and durations and concerns of venous thromboembolism (VTE) prophylaxis was sent to 2000 orthopaedic surgeons nationwide, and 1720 (86%) surgeons responded. Statistical analyses were conducted to assess all respondents' results and to compare differences among subgroups that were stratified according to city and hospital level, as well as their professional title. Results According to the results of the survey, ERAS awareness was high (65.1%) and most surgeons recognized the importance of thromboprophylaxis. However, the timing of ERAS was not consistent, with 22.8%, 31.9%, and 37.7% of surgeons choosing to initiate pharmaceutical prophylaxis within <6 h, 6–12 h, and 12–24 h after surgery, respectively. Low‐molecular‐weight heparin was mainly selected during hospitalization, and new oral anticoagulants (NOACs) were the first choice after discharge. Regarding postoperative antithrombotic therapy, particularly when combined with analgesics, the potential bleeding risk was mostly considered (80.0%)Tranexamic acid was believed to have no effect on the timing of NOAC therapy initiation (56.2%). Most of the above outcomes were influenced by the hospital level and professional title of the surgeon. Surgeons who had higher awareness on ERAS and better adhered to the guidelines were from higher‐level hospitals as well as had more advanced professional titles. City level partly might influence their practice but not impact surgeons' awareness. Conclusions The awareness and perception of the concept of ERAS and prophylactic antithrombotic regimens remain different among Chinese orthopaedic surgeons in different level cities and with various professional titles. Continuing medical educations (CME) on VTE prophylaxis is needed for improving the quality of health care in China.
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Affiliation(s)
- Xi-Sheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Juan Liu
- Medical Affairs Department, Pfizer Inc, Shanghai, China
| | - Duo Wu
- Medical Affairs Department, Pfizer Inc, Guangzhou, China
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Scibelli G, Maio L, Savoia G. Corrected and republished from: Regional anesthesia and antithrombotic agents: instructions for use. Minerva Anestesiol 2020; 86:341-353. [DOI: 10.23736/s0375-9393.20.14494-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Dmytriiev D, Lysak Y, Glazov Y, Geranin S, Zaletska O. Mini-invasive methods of treatment of diabetic foot pain. PAIN MEDICINE 2019. [DOI: 10.31636/pmjua.v4i3.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Neuropathic pain occurs with diabetic polyneuropathy more often than with all polyneuropathies of another etiology. Because the cause of pain can rarely be cured, treatment is usually symptomatic. Neuropathic pain is usually poorly controlled by analgesics. Management of neuropathic pain is started with conservative pharmacotherapy before invasive pain management is applied. Although there are many drugs that can be used in patients with diabetic pain syndrome, pain syndrome can not be surely stoped with monotherapy. In addition, the patient may not tolerate the full therapeutic dose of the drug.
All this dictates the need for combination therapy. It is believed that regional anesthesia as an independent type of analgesia or a component of combined anesthesia is the method of choice for the elderly and senile patients. The main reasons for this choice, when comparing regional anesthesia with narcosis, are less stressful response of the organism, absence of depression of the central nervous system, stable reliable analgesia with complete blockade of nociceptive reflexes with the provision of adequate muscle relaxation, prevention of neurovegetative reactions, which ultimately helps to reduce the incidence of postoperative complications and mortality. Clinicians have accumulated considerable experience demonstrating the need for regional analgesia in the management of diabetic foot pain.
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Godier A, Bloc S. How to deal with peripheral regional anaesthesia while antithrombotics on board? Anaesth Crit Care Pain Med 2019; 38:457-459. [PMID: 31585764 DOI: 10.1016/j.accpm.2019.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Anne Godier
- Service d'anesthésie-réanimation, Hôpital Européen Georges-Pompidou, AP-HP, Paris, France; Inserm UMRS 1140, Faculté de Pharmacie, Université Paris Descartes, Paris, France.
| | - Sébastien Bloc
- CMC Ambroise-Paré, Département d'anesthésie, Neuilly-sur-Seine, France
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Lamperti M, Khozenko A, Kumar A. Perioperative Management of Patients Receiving New Anticoagulants. Curr Pharm Des 2019; 25:2149-2157. [PMID: 31560280 DOI: 10.2174/1381612825666190709220449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/25/2019] [Indexed: 01/01/2023]
Abstract
There is an increased use of oral anticoagulants for the prevention of venous and arterial thrombosis. Vitamin-K antagonists have been used for decades as the main oral anticoagulants but they have the draback a complex therapeutic management, slow onset of action and by a different oral intake caused by dietary vitamin K intake. New non-vitamin K antagonist oral anticoagulants (NOACs) have been developed to overcome the limitations of warfarin. Their management is easier as it requires a fixed daily dose without coagulation monitoring. Although their therapeutic profile is safe, proper attention should be paid in case of unexpected need for the reversal of their coagulation effect and in case a patient needs to have a scheduled surgery. For non-acute cardiac surgery, discontinuation of NOACs should start at least 48 hours prior surgery. Intracranial bleedings associated with NOACs are less dangerous comparing to those warfarin-induced. NOACs need to be stopped ≥24 hours in case of elective surgery for low bleeding-risk procedures and ≥48 hours for high bleeding-risk surgery in patients with normal renal function and 72 hours in case of reduced CrCl < 80. The therapy with NOACs should be resumed from 48 to 72 hours after the procedure depending on the perceived bleeding, type of surgery and thrombotic risks. There are some available NOAC reversal agents acting within 5 to 20 minutes. In case of lack of reversal agent, adequate diuresis, renal replacement therapy and activated charcoal in case of recent ingestion should be considered.
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Affiliation(s)
- Massimo Lamperti
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Andrey Khozenko
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Arun Kumar
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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Zhang W, Zhang PX. [Analysis of prophylactic effect of extended-duration anticoagulant drugs in elderly patients undergoing hip fracture]. JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2019; 51:501-504. [PMID: 31209422 DOI: 10.19723/j.issn.1671-167x.2019.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the prophylactic effect of extended-duration anticoagulant drugs on venous thromboembolism, and to explore the time of drug prevention for venous thromboembolism after hip fracture. METHODS A retrospective analysis of 143 patients undergoing hip fractures from November 2017 to October 2018 in Peking University People's Hospital was conducted to investigate the relationship between the extended-duration anticoagulant drug and the morbidity of venous thromboembolism and bleeding during the treatment. All the drug prevention programs for the patients included in the study were implemented in accordance with the 2016 edition of the Guidelines for Prevention of Venous Thrombosis in Orthopaedic Surgery by Orthopaedic Society of Chinese Medical Association. The patients in the two groups were followed up for venous thromboembolism and bleeding during the medication within 5 weeks after the fracture. Venous thromboembolism included symptomatic and asymptomatic deep venous thrombosis of the lower extremities, pulmonary thromboembolism, and all the patients with deep venous thrombosis of the lower extremities required vascular ultrasound results to obtain clear evidence. The results of vascular ultrasound were the basis for determining deep venous thrombosis. Bleeding conditions were included, but not limited to gastrointestinal bleeding, wound bleeding, intracranial hemorrhage, intraspinal hematoma, and fundus hemorrhage. RESULTS There were no pulmonary thromboembolism in both groups after surgery. The morbidity of deep venous thrombosis was 22.09% and 8.77% in the 2-week and 4-week groups (P=0.037), the time to deep venous thrombosis in the two groups was (17.32±7.75) days and (29.20±0.17) days after surgery. One case of bleeding occurred during the use of anticoagulant drugs in both groups, the morbidity of bleeding during the treatment was 1.16% and 1.75% (P=0.769), respectively. CONCLUSION Extended-duration anticoagulant drugs to 4 weeks after surgery can significantly reduce the morbidity of postoperative venous thromboembolism, and does not increase the risk of bleeding. Patients with a risk of bleeding should carefully assess the risks and benefits of drug prevention and choose the best treatment.
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Affiliation(s)
- W Zhang
- Department of Trauma and Orthopaedics, Peking University People's Hospital, Beijing 100044, China
| | - P X Zhang
- Department of Trauma and Orthopaedics, Peking University People's Hospital, Beijing 100044, China
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Spahn DR, Beer JH, Borgeat A, Chassot PG, Kern C, Mach F, Nedeltchev K, Korte W. NOACs in Anesthesiology. Transfus Med Hemother 2019; 46:282-293. [PMID: 31700511 DOI: 10.1159/000491400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/17/2018] [Indexed: 12/29/2022] Open
Abstract
Background Due to increasing use of new oral anticoagulants (NOACs), clinicians are faced more and more frequently with clinical issues related to these drugs. Objective The objective of this publication is to make practical suggestions for the perioperative management of NOACs as well as for their handling in overdoses and bleedings. Recommendations In elective surgery and creatinine clearance ≥ 50 ml/min, a NOAC should be discontinued 24-36 h before the intervention, and even earlier in case of reduced kidney function. In emergency interventions that cannot be delayed, the management is dependent on the NOAC plasma levels. With levels ≤ 30 ng/ml, surgery can be performed. With levels >30 ng/ml, reversal agents should be considered. In low bleeding risk surgery, NOACs can be re-started 24 h after the intervention, which is prolonged to 48-72 h after surgery with high bleeding risk. In case of NOAC overdose and minor bleedings, temporary discontinuation and supportive care are usually sufficient to control the situation. In severe or life-threatening bleedings, nonspecific and specific reversal agents should be considered.
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Affiliation(s)
- Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Jürg-Hans Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, Baden, Switzerland
| | - Alain Borgeat
- Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Pierre-Guy Chassot
- Formerly Department of Anesthesiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Christian Kern
- Department of Anesthesiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - François Mach
- Department of Internal Medicine, University Hospitals of Geneva (HUG), Geneva, Switzerland
| | | | - Wolfgang Korte
- Center for Laboratory Medicine; Hemostasis and Hemophilia Center, St. Gallen, Switzerland
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Kato M, Uedo N, Hokimoto S, Ieko M, Higuchi K, Murakami K, Fujimoto K. Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment: 2017 Appendix on Anticoagulants Including Direct Oral Anticoagulants. Dig Endosc 2018; 30:433-440. [PMID: 29733468 DOI: 10.1111/den.13184] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/28/2018] [Indexed: 02/06/2023]
Abstract
In 2012, the Japan Gastroenterological Endoscopy Society published "Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment" concerning thromboembolism associated with antithrombotic therapy withdrawal. Since then, physicians have started prescribing oral anticoagulants, creating a need for standards reflecting their use in clinical practice. Therefore, new findings regarding anticoagulants are included in this appendix. However, the evidence levels are low for many statements contained herein and these appended guidelines still need to be verified in clinical settings.
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Affiliation(s)
- Mototsugu Kato
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Noriya Uedo
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Seiji Hokimoto
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Masahiro Ieko
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kazuhide Higuchi
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kazunari Murakami
- Committee of 2017 Appendix on Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kazuma Fujimoto
- Guidelines Committee, Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy. Reg Anesth Pain Med 2018; 43:263-309. [DOI: 10.1097/aap.0000000000000763] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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17
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition). Reg Anesth Pain Med 2017; 43:225-262. [DOI: 10.1097/aap.0000000000000700] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kreutz R, Llau J, Norrving B, Haas S, Turpie A. Management consensus guidance for the use of rivaroxaban – an oral, direct factor Xa inhibitor. Thromb Haemost 2017; 108:876-86. [PMID: 23014816 DOI: 10.1160/th12-03-0209] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 08/22/2012] [Indexed: 12/31/2022]
Abstract
SummaryA number of novel oral anticoagulants that directly target factor Xa or thrombin have been developed in recent years. Rivaroxaban and apixaban (direct factor Xa inhibitors) and dabigatran etexilate (a direct thrombin inhibitor) have shown considerable promise in large-scale, randomised clinical studies for the management of thromboembolic disorders, and have been approved for clinical use in specific indications. Rivaroxaban is licensed for the prevention of venous thromboembolism in patients undergoing elective hip or knee replacement surgery, the treatment of deep-vein thrombosis and prevention of recurrent venous thromboembolism, and for stroke prevention in patients with non-valvular atrial fibrillation. Based on the clinical trial data for rivaroxaban, feedback on its use in clinical practice and the authors’ experience with the use of rivaroxaban, practical guidance for the use of rivaroxaban in special patient populations and specific clinical situations is provided. Although most recommendations are in line with the European summary of product characteristics for the approved indications, additional and, in several areas, different recommendations are given based on review of the literature and the authors’ clinical experience.
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Zhang J, Chen X, Wang J, Liu Z, Wang X, Ren J, Sun T. Poor prognosis after surgery for intertrochanteric fracture in elderly patients with clopidogrel treatment: A cohort study. Medicine (Baltimore) 2017; 96:e8169. [PMID: 28953670 PMCID: PMC5626313 DOI: 10.1097/md.0000000000008169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Choice of surgical approach in patients under clopidogrel treatment is controversial. Intertrochanteric fractures are common in the elderly, who also suffer from a number of comorbidities.The aim of this study is to assess the prognosis of elderly patients with clopidogrel treatment after surgery for intertrochanteric fracture.This was a cohort study of 238 elderly patients who underwent proximal femur intramedullary nailing for intertrochanteric fracture between January 2012 and December 2013 at the Geriatric Trauma Center of the Beijing Army General Hospital. The patients were divided into the clopidogrel (n = 32) and control (n = 206) groups according to their history of long-term clopidogrel treatment before surgery. Demographic and clinical characteristics, intraoperative parameters, postoperative complications, and 1-year survival were compared between the 2 groups.Preoperative American Society of Anesthesiologists (ASA) grade and the frequency of arterial stenting were different between the 2 groups (P = .002 and P < .001, respectively). The rate of intraoperative blood transfusion, ICU stay, and hospital stay were higher in the clopidogrel group compared with the control group (all P < .001). Postoperative complications were similar in the 2 groups. The 1-year mortality rate after surgery was significantly higher in the clopidogrel group compared with the control group (37.5% vs 20.3%, P = .030).Prognosis after surgery for intertrochanteric fracture was poorer in elderly patients with clopidogrel treatment; these patients had lower 1-year survival, more intraoperative blood transfusion, longer ICU stay, and longer hospital stay. ASA grade, arterial stenting, and anesthesia mode were prognostic factors.
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Abstract
Novel anticoagulants (NAGs) have emerged as the preferred alternatives to vitamin K antagonists. In patients being considered for regional anesthesia, these drugs present a layer of complexity in the preprocedure evaluation. There are no established tests to monitor anticoagulant activity and our experience is short with these drugs. These authors believe it is important to review the relevant hematology, orthopedics, and anesthesiology literature to provide a valuable reference for the clinician who is met with these challenges. In addition to discussing NAGs, we also review the existing American Society of Regional Anesthesia guidelines for heparin, low-molecular-weight heparin, and antiplatelet agents.
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Affiliation(s)
- Mudit Kaushal
- Department of Anesthesiology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
| | - Ryan E Rubin
- Department of Anesthesiology, Louisiana State University School of Medicine, 1542 Tulane Avenue, Room 658, New Orleans, LA 70112, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University School of Medicine, 1542 Tulane Avenue, Room 658, New Orleans, LA 70112, USA
| | - Karina Gritsenko
- Department of Anesthesiology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
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Dubois V, Dincq AS, Douxfils J, Ickx B, Samama CM, Dogné JM, Gourdin M, Chatelain B, Mullier F, Lessire S. Perioperative management of patients on direct oral anticoagulants. Thromb J 2017; 15:14. [PMID: 28515674 PMCID: PMC5433145 DOI: 10.1186/s12959-017-0137-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 05/04/2017] [Indexed: 12/31/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10-15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure. As antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests.
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Affiliation(s)
- Virginie Dubois
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Brigitte Ickx
- Université Libre de Bruxelles, Erasme University Hospital,Department of Anesthesiology, Brussels, Belgium
| | - Charles-Marc Samama
- Université Paris Descartes, Cochin University Hospital,Department of Anesthesiology and Intensive Care, Paris, France
| | - Jean-Michel Dogné
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Maximilien Gourdin
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Bernard Chatelain
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - Sarah Lessire
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
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Beyer-Westendorf J, Mouret P, Turpie AG. Rivaroxaban for venous thromboembolism prevention after major orthopedic surgery: translating trial data into routine clinical practice. Orthop Res Rev 2017; 9:1-11. [PMID: 30774472 PMCID: PMC6209349 DOI: 10.2147/orr.s105227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
An established standard of care for the prevention of venous thromboembolism after major orthopedic surgery has been subcutaneous low-molecular-weight heparin. The non-vitamin K antagonist oral anticoagulant rivaroxaban has demonstrated superior efficacy and similar safety to all tested regimens of enoxaparin in large Phase III clinical studies of venous thromboembolism prevention after elective hip and knee arthroplasty. Despite regulatory approval of rivaroxaban for this indication, concerns remain among physicians regarding its optimal and effective use in routine clinical practice. Real-life studies, such as XAMOS and ORTHO-TEP, are providing physicians with more information on the routine use of rivaroxaban for venous thromboembolism prevention after orthopedic surgery, helping to establish its safety and effectiveness in everyday clinical care. Among the most important issues are the risk of bleeding complications, wound healing, timing of first dose, impact of type of anesthesia on thromboprophylaxis effectiveness, patient comorbidities and comedication use, periprocedural management, associated costs, and clinical outcomes in trauma-related fractures. Many of these issues are difficult to study in randomized, double-blind, Phase III trials, and can be assessed more readily using real-life data. In particular, real-life or noninterventional studies lack many of the strict inclusion and exclusion criteria associated with Phase III trials and involve unselected patients who often present with significant comorbidities or comedication use.
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Affiliation(s)
| | - Patrick Mouret
- Orthopedic Clinic, Klinikum Frankfurt Höchst GmbH, Frankfurt, Germany
| | - Alexander Gg Turpie
- Department of Medicine, General Division, Hamilton Health Sciences, Hamilton, ON, Canada
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Albaladejo P, Bonhomme F, Blais N, Collet JP, Faraoni D, Fontana P, Godier A, Llau J, Longrois D, Marret E, Mismetti P, Rosencher N, Roullet S, Samama CM, Schved JF, Sié P, Steib A, Susen S. Management of direct oral anticoagulants in patients undergoing elective surgeries and invasive procedures: Updated guidelines from the French Working Group on Perioperative Hemostasis (GIHP) - September 2015. Anaesth Crit Care Pain Med 2016; 36:73-76. [PMID: 27659969 DOI: 10.1016/j.accpm.2016.09.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 09/09/2016] [Indexed: 11/16/2022]
Abstract
Since 2011, data on patients exposed to direct oral anticoagulants (DOAs) while undergoing invasive procedures have accumulated. At the same time, an increased hemorrhagic risk during perioperative bridging anticoagulation without thrombotic risk reduction has been demonstrated. This has led the GIHP to update their guidelines published in 2011. For scheduled procedures at low bleeding risk, it is suggested that patients interrupt DOAs the night before irrespective of type of drug and to resume therapy six hours or more after the end of the invasive procedure. For invasive procedures at high bleeding risk, it is suggested to interrupt rivaroxaban, apixaban and edoxaban three days before. Dabigatran should be interrupted according to the renal function, four days and five days if creatinine clearance is higher than 50mL/min and between 30 and 50mL/min, respectively. For invasive procedures at very high bleeding risk such as intracranial neurosurgery or neuraxial anesthesia, longer interruption times are suggested. Finally, bridging with parenteral anticoagulation and measurement of DOA concentrations can no longer routinely be used.
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Affiliation(s)
- Pierre Albaladejo
- Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble-Alpes, 38043 Grenoble, France.
| | - Fanny Bonhomme
- Division of Anesthesiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Normand Blais
- Department de Medicine - University of Montréal, CHUM - Hôpital Notre-Dame, Montréal, Quebec, Canada
| | - Jean-Philippe Collet
- Univ Paris 06 (UPMC), ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (APHP), Paris, France
| | - David Faraoni
- Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Pierre Fontana
- Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Anne Godier
- Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Juan Llau
- Department of Anesthesiology and Critical Care. Hospital Clínic Universitari, Valencia, Spain
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, University Paris Diderot, Sorbonne Paris Cité, U1148 INSERM, Paris, France
| | - Emmanuel Marret
- Department of Anesthesiology, American Hospital of Paris & Institut Hospitalier Franco-Britannique
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Nadia Rosencher
- Department of Anaesthesia and Intensive Care Medicine, Cochin and Hôtel-Dieu University Hospitals, Paris Descartes University, Paris, France
| | - Stéphanie Roullet
- Department of Anaesthesia and Intensive Care Medicine, Cochin and Hôtel-Dieu University Hospitals, Paris Descartes University, Paris, France
| | - Charles-Marc Samama
- Service d'Anesthésie Réanimation 1, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | | | - Pierre Sié
- Department of Hematology, Toulouse University Hospital, Toulouse, France
| | - Annick Steib
- Department of Anesthesiology and Intensive Care, University Hospital, Strasbourg, France
| | - Sophie Susen
- Department of Hematology and Transfusion, Lille University Hospital, Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
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Haas S, Holberg G, Kreutz R, Lassen MR, Mantovani L, Haupt V, Vogtländer K, Turpie AG. The effects of timing of prophylaxis, type of anesthesia, and use of mechanical methods on outcome in major orthopedic surgery - subgroup analyses from 17,701 patients in the XAMOS study. Vasc Health Risk Manag 2016; 12:209-18. [PMID: 27274266 PMCID: PMC4876074 DOI: 10.2147/vhrm.s100293] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Real-world data on the use of rivaroxaban in the perioperative period in patients undergoing major orthopedic surgery are limited. Subsets of data from the Phase IV, non-interventional XAMOS study were analyzed to explore the potential influence of timing of the first thrombo prophylactic dose, type of anesthesia, and concomitant mechanical prophylaxis on clinical outcomes in patients undergoing major orthopedic surgery in routine clinical practice. PATIENTS AND METHODS In XAMOS, 8,778 patients received rivaroxaban (10 mg once daily) and 8,635 received standard-of-care (SOC) pharmacological prophylaxis (safety population). Crude incidences of symptomatic thromboembolic and treatment-emergent bleeding events were analyzed according to timing of the first postoperative thromboprophylactic dose, use of general or neuraxial anesthesia, and use of mechanical prophylaxis with pharmacological thromboprophylaxis. RESULTS In the rivaroxaban group, the incidences of symptomatic thromboembolic events were 0.7%, 1.0%, and 0.7% in patients receiving the first thromboprophylactic dose at ≤6 hours, >6 hours to ≤10 hours, and >10 hours to ≤24 hours after surgery, respectively. In the SOC group, the incidence of symptomatic thromboembolic events was slightly higher when the postoperative dose was given at >10 hours to ≤24 hours (1.8% vs 1.1% at ≤6 hours and 1.3% at >6 hours to ≤10 hours). The antithrombotic effect of rivaroxaban was maintained in comparison to the SOC group. The incidence of major bleeding (RECORD trial definition) was low and similar between the two treatment groups and was not influenced by timing of the first thromboprophylactic dose. Neuraxial anesthesia was used more than any other form of anesthesia for both hip and knee surgery; the effectiveness of rivaroxaban was not influenced by the type of anesthesia used. No spinal hematomas were reported in patients receiving neuraxial anesthesia in either treatment group. Use of mechanical thromboprophylaxis in addition to rivaroxaban or SOC pharmacological prophylaxis did not reduce the risk of thromboembolic events further. CONCLUSION The effectiveness and safety of rivaroxaban in patients undergoing major orthopedic surgery in routine clinical practice were maintained irrespective of timing of the first postoperative dose within 24 hours after surgery, the type of anesthesia, and the additional use of mechanical thromboprophylaxis.
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Affiliation(s)
- Sylvia Haas
- Formerly Technical University of Munich, Berlin, Germany
| | | | - Reinhold Kreutz
- Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin, Berlin, Germany
| | | | - Lorenzo Mantovani
- CESP-Center for Public Health Research, University of Milan-Bicocca, Monza, Italy
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Cappelleri G, Fanelli A. Use of direct oral anticoagulants with regional anesthesia in orthopedic patients. J Clin Anesth 2016; 32:224-35. [PMID: 27290980 DOI: 10.1016/j.jclinane.2016.02.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 01/05/2016] [Accepted: 02/22/2016] [Indexed: 12/11/2022]
Abstract
The use of direct oral anticoagulants including apixaban, rivaroxaban, and dabigatran, which are approved for several therapeutic indications, can simplify perioperative and postoperative management of anticoagulation. Utilization of regional neuraxial anesthesia in patients receiving anticoagulants carries a relatively small risk of hematoma, the serious complications of which must be acknowledged. Given the extensive use of regional anesthesia in surgery and the increasing number of patients receiving direct oral anticoagulants, it is crucial to understand the current clinical data on the risk of hemorrhagic complications in this setting, particularly for anesthesiologists. We discuss current data, guideline recommendations, and best practice advice on effective management of the direct oral anticoagulants and regional anesthesia, including in specific clinical situations, such as patients undergoing major orthopedic surgery at high risk of a thromboembolic event, or patients with renal impairment at an increased risk of bleeding.
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Affiliation(s)
- Gianluca Cappelleri
- Anaesthesia and Intensive Care Unit, Azienda Ospedaliera Istituto Ortopedico Gaetano Pini, 20122, Milan, Italy.
| | - Andrea Fanelli
- Anaesthesia and Intensive Care Unit, Policlinico S. Orsola-Malpighi, 40138, Bologna, Italy.
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Soo CGKM, Della Torre PK, Yolland TJ, Shatwell MA. Clopidogrel and hip fractures, is it safe? A systematic review and meta-analysis. BMC Musculoskelet Disord 2016; 17:136. [PMID: 27005816 PMCID: PMC4804516 DOI: 10.1186/s12891-016-0988-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/16/2016] [Indexed: 12/22/2022] Open
Abstract
Background Femoral neck fractures in the elderly make up a large proportion of Orthopaedic surgical admissions each year. Operating on patients with clopidogrel poses a challenge because of the risk of bleeding and the difficulty deciding the optimal timing of surgery. The aim of this systematic review is to examine the published evidence to establish a set of guidelines for approaching neck of femur patients who are on clopidogrel. Methods All comparative studies with an intervention group and a control group were considered. Data on patient blood transfusion exposures, units transfused, haemoglobin concentration and drop in haemoglobin were extracted and pooled using the fixed effects model. Heterogeneity of the intervention effect was assessed with the I2 statistic. Results A total of 4219 studies were identified. After removal of duplicates and after exclusion criteria were applied, there were 14 studies to be included. All 14 were case series with controls. There was no significant heterogeneity amongst the studies. Pooled odds ratio for transfusion exposures was 1.24 (95 % confidence interval 0.91 to 1.71) however this was not statistically significant (p = 0.14). No significant mean differences were found for other primary outcome measures. Conclusions On the available evidence, we recommend that these patients can be managed by normal protocols with early surgery. Operating early on patients on clopidogrel is safe and does not appear to confer any clinically significant bleeding risk. As reported in other studies, we believe clopidogrel, if possible, should not be withheld throughout the perioperative period due to increased risk of cardiovascular events associated with stopping clopidogrel. Care should be taken intraoperatively to minimise blood loss due to the increased potential for bleeding. Trial registration This systematic review and meta-analysis has been registered on Research Registry on July 16, 2015. The Review Registry Unique Identifying Number is: reviewregistry61. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-0988-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christopher G K M Soo
- Orthopaedic surgery department, Port Macquarie Base Hospital, Wrights Rd, Port Macquarie, NSW, 2444, Australia.
| | - Paul K Della Torre
- Orthopaedic surgery department, Concord Repatriation General Hospital, Hospital Rd, Concord, NSW, 2139, Australia
| | - Tristan J Yolland
- Orthopaedic surgery department, John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW, 2305, Australia
| | - Michael A Shatwell
- Orthopaedic surgery department, Port Macquarie Base Hospital, Wrights Rd, Port Macquarie, NSW, 2444, Australia
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Johnston D, Stafford M, McKinney M, Deyermond R, Dane K. Peripheral nerve blocks with sedation using propofol and alfentanil target-controlled infusion for hip fracture surgery: a review of 6 years in use. J Clin Anesth 2016; 29:33-9. [DOI: 10.1016/j.jclinane.2015.10.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 06/10/2015] [Accepted: 10/14/2015] [Indexed: 11/27/2022]
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Li J, Halaszynski T. Neuraxial and peripheral nerve blocks in patients taking anticoagulant or thromboprophylactic drugs: challenges and solutions. Local Reg Anesth 2015; 8:21-32. [PMID: 26347411 PMCID: PMC4531015 DOI: 10.2147/lra.s55306] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Incidence of hemorrhagic complications from neuraxial blockade is unknown, but classically cited as 1 in 150,000 epidurals and 1 in 220,000 spinals. However, recent literature and epidemiologic data suggest that for certain patient populations the frequency is higher (1 in 3,000). Due to safety concerns of bleeding risk, guidelines and recommendations have been designed to reduce patient morbidity/mortality during regional anesthesia. Data from evidence-based reviews, clinical series and case reports, collaborative experience of experts, and pharmacology used in developing consensus statements are unable to address all patient comorbidities and are not able to guarantee specific outcomes. No laboratory model identifies patients at risk, and rarity of neuraxial hematoma defies prospective randomized study so “patient-specific” factors and “surgery-related” issues should be considered to improve patient-oriented outcomes. Details of advanced age, older females, trauma patients, spinal cord and vertebral column abnormalities, organ function compromise, presence of underlying coagulopathy, traumatic or difficult needle placement, as well as indwelling catheter(s) during anticoagulation pose risks for significant bleeding. Therefore, balancing between thromboembolism, bleeding risk, and introduction of more potent antithrombotic medications in combination with regional anesthesia has resulted in a need for more than “consensus statements” to safely manage regional interventions during anticoagulant/thromboprophylactic therapy.
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Affiliation(s)
- Jinlei Li
- Department of Anesthesiology, Yale University, Yale New Haven Hospital, New Haven, CT, USA
| | - Thomas Halaszynski
- Department of Anesthesiology, Yale University, Yale New Haven Hospital, New Haven, CT, USA
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Improving Adherence to Practice Guidelines for Anticoagulation in Patients Receiving Neuraxial Anesthesia Using an Electronic Order Entry Alert System. J Patient Saf 2015; 15:218-223. [PMID: 26076079 DOI: 10.1097/pts.0000000000000219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Epidural analgesia is frequently used to alleviate postoperative pain. Though rare, epidural hematoma continues to be a feared complication of neuraxial analgesia. The risk of epidural hematoma is likely increased when certain regimens are used for prophylaxis/treatment of venous thromboembolism. To help decrease the risk, we developed an alert in our electronic medical record to assist providers with adherence to published guidelines addressing neuraxial analgesia and anticoagulation. METHODS Patient data were collected retrospectively 3 months before and 3 months after the initiation of the computerized alert to assess the effectiveness of the alert. Patients were included if they had a procedure code associated with epidural analgesia. Pregnant patients and children were excluded. Type and frequency of antithrombotic medications were recorded for comparison to published practice guidelines. RESULTS Using Poisson regression to describe the data, patients with epidurals after the best practice alert observed a 61% decrease in the expected number of days of exposure to inappropriate doses of anticoagulation versus patients treated before implementation of the alert. CONCLUSION Unapproved antithrombotic administration was significantly reduced after initiation of the alert system. This simple electronic alert was found to have a protective effect for patients receiving both anticoagulation and epidural analgesia.
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Epidural catheter removal for initiation of emergency anticoagulant therapy in acute coronary syndrome--when is the time right? Eur J Anaesthesiol 2015; 32:582-4. [PMID: 25603388 DOI: 10.1097/eja.0000000000000212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications. Reg Anesth Pain Med 2015; 40:182-212. [DOI: 10.1097/aap.0000000000000223] [Citation(s) in RCA: 195] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Arcelus JI, Domènech P, Fernández-Capitan MDC, Guijarro R, Jiménez D, Jiménez S, Lozano FS, Monreal M, Nieto JA, Páramo JA. Rivaroxaban in the Treatment of Venous Thromboembolism and the Prevention of Recurrences. Clin Appl Thromb Hemost 2014; 21:297-308. [DOI: 10.1177/1076029614561321] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Anticoagulation therapy is the standard treatment of patients with symptomatic venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism. Until recently, treatment of VTE was based on parenteral or low-molecular-weight heparin for initial therapy (5-10 days) and oral vitamin K antagonists for long-term therapy. Those treatments have some limitations, including parenteral administration (heparins), the need for frequent monitoring and dose adjustments, interactions with several medications, and dietary restrictions (vitamin K antagonists). Rivaroxaban is a new oral direct factor Xa inhibitor with a wide therapeutic window, predictable anticoagulant effect, no food interactions, and few drug interactions. Consequently, no periodic monitoring of anticoagulation is needed, and fixed doses can be prescribed. EINSTEIN program demonstrated that rivaroxaban was as effective as and significantly safer than standard therapy for treatment of VTE. Rivaroxaban was recently authorized so doubts exist about how to use it in daily clinical practice. This document aims to clarify common questions formulated by clinicians regarding the use of this new drug.
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Affiliation(s)
- Juan I. Arcelus
- Department of Surgery, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Pere Domènech
- Haemostasis and Thrombosis Department. Bellvitge's University Hospital. Hospitalet de Llobregat, Barcelona, Spain
| | | | - Ricardo Guijarro
- Internal Medicine Department, Regional University Hospital of Malaga (Carlos Haya Hospital), Málaga, Spain
| | - David Jiménez
- Respiratory Department, Ramon y Cajal Hospital, Alcala de Henares University, Madrid, Spain
| | - Sonia Jiménez
- Emergency Department, Hospital Clínic and IDIBAPS, Barcelona, Spain
| | | | - Manel Monreal
- Internal Medicine Department, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - José A. Nieto
- Internal Medicine Service, Hospital Virgen de la Luz, Cuenca, Spain
| | - José A. Páramo
- Hematology Service, Clínica Universidad de Navarra, Pamplona, Spain
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Yamashita YI, Bekki Y, Imai D, Ikegami T, Yoshizumi T, Ikeda T, Kawanaka H, Nishie A, Shirabe K, Maehara Y. Efficacy of postoperative anticoagulation therapy with enoxaparin for portal vein thrombosis after hepatic resection in patients with liver cancer. Thromb Res 2014; 134:826-31. [PMID: 25156238 DOI: 10.1016/j.thromres.2014.07.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/05/2014] [Accepted: 07/28/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUNDS Enoxaparin, low-molecular-weight heparin, has become a routine thromboprophylaxis in general surgery. STUDY DESIGN A retrospective cohort study was performed in 281 patients who underwent hepatic resections for liver cancers from 2011 to 2013. These patients were divided into two groups; an enoxaparin (-) group (n=228) and an enoxaparin (+) group (n=53). Short-term surgical results including venous thromboembolism (VTE) and portal vein thrombosis (PVT) were compared. RESULTS In the enoxaparin (+) group, the patients' age (65 vs. 69 years; p=0.01) and BMI (22.9 vs. 24.4; p<0.01) were significantly higher. According to the symptomatic VTE, symptomatic pulmonary embolism occurred in one patient (0.4%) in the enoxaparin (-) group, but the complication rate was not significantly different (p=0.63). The complication rate of PVT was significantly lower in the enoxaparin (+) group (10 vs. 2%; p=0.04). The independent risk factors for PVT were an operation time ≥ 300 minutes (Odds ratio 6.66) and non-treatment with enoxaparin (Odds ratio 2.49). CONCLUSIONS Postoperative anticoagulant therapy with enoxaparin could prevent PVT in patients who underwent hepatic resection for liver cancers.
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Affiliation(s)
- Yo-Ichi Yamashita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Yuki Bekki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Daisuke Imai
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Tetsuo Ikeda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Hirofumi Kawanaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Akihiro Nishie
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Ken Shirabe
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Perioperative management of patients receiving new oral anticoagulants: an international survey. Clin Lab Med 2014; 34:637-54. [PMID: 25168948 DOI: 10.1016/j.cll.2014.06.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
New oral anticoagulants (NOACs) are increasingly replacing standard anticoagulants. These new drugs have been recently introduced in clinical practice, and specific knowledge regarding preoperative interruption, anticoagulation assessment, and reversal therapies is needed. In this article, 3 main areas related to perioperative NOACs management are discussed: (1) physicians' knowledge, (2) current practices, and (3) perspectives to improve management of patients treated with NOACs.
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Preventive strategies against bleeding due to nonvitamin K antagonist oral anticoagulants. BIOMED RESEARCH INTERNATIONAL 2014; 2014:616405. [PMID: 25032218 PMCID: PMC4084591 DOI: 10.1155/2014/616405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 04/14/2014] [Indexed: 01/20/2023]
Abstract
Dabigatran etexilate (DE), rivaroxaban, and apixaban are nonvitamin K antagonist oral anticoagulants (NOACs) that have been compared in clinical trials with existing anticoagulants (warfarin and enoxaparin) in several indications for the prevention and treatment of thrombotic events. All NOACs presented bleeding events despite a careful selection and control of patients. Compared with warfarin, NOACs had a decreased risk of intracranial hemorrhage, and apixaban and DE (110 mg BID) had a decreased risk of major bleeding from any site. Rivaroxaban and DE showed an increased risk of major gastrointestinal bleeding compared with warfarin. Developing strategies to minimize the risk of bleeding is essential, as major bleedings are reported in clinical practice and specific antidotes are currently not available. In this paper, the following preventive approaches are reviewed: improvement of appropriate prescription, identification of modifiable bleeding risk factors, tailoring NOAC's dose, dealing with a missed dose as well as adhesion to switching, bridging and anesthetic procedures.
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Transient paraplegia after epidural catheter removal during low molecular heparin prophylaxis. Eur J Anaesthesiol 2014; 31:175-6. [DOI: 10.1097/eja.0b013e328364567b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Martins Fonseca N, Rodrigues Alves R, Pontes JPJ. Recomendações da SBA para segurança na anestesia regional em uso de anticoagulantes. Rev Bras Anestesiol 2014. [DOI: 10.1016/j.bjan.2013.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Fonseca NM, Alves RR, Pontes JPJ. SBA recommendations for regional anesthesia safety in patients taking anticoagulants. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2014; 64:1-15. [PMID: 24565383 DOI: 10.1016/j.bjane.2013.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 04/28/2013] [Indexed: 06/03/2023]
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Klauser W, Dütsch M. Practical management of new oral anticoagulants after total hip or total knee arthroplasty. Musculoskelet Surg 2013; 97:189-97. [PMID: 24249360 PMCID: PMC3838782 DOI: 10.1007/s12306-013-0306-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 11/04/2013] [Indexed: 01/12/2023]
Abstract
Within the past 5 years, the oral anticoagulants rivaroxaban, apixaban, and dabigatran etexilate have been approved for the prevention of venous thromboembolism in adult patients after elective hip or knee arthroplasty in the European Union and many other countries worldwide. These agents differ from the previously available anticoagulants because they selectively and directly inhibit a single factor in the coagulation cascade-rivaroxaban and apixaban inhibit Factor Xa, and dabigatran inhibits Factor IIa (thrombin)-potentially enhancing the predictability of their anticoagulant effect. Currently, although some guidelines provide recommendations for the use of rivaroxaban, dabigatran etexilate, and apixaban in clinical practice, there are still questions regarding the optimal practical management of patients receiving these agents. This article briefly reviews the practical limitations associated with conventional anticoagulants, discusses potential issues with the practical management of the newer oral anticoagulants, and provides clinical experience from a single institution where rivaroxaban and dabigatran etexilate have been used within their approved indications.
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MESH Headings
- Anti-Inflammatory Agents, Non-Steroidal/adverse effects
- Anti-Inflammatory Agents, Non-Steroidal/pharmacology
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Anticoagulants/administration & dosage
- Anticoagulants/adverse effects
- Anticoagulants/pharmacology
- Anticoagulants/therapeutic use
- Arthroplasty, Replacement, Hip
- Arthroplasty, Replacement, Knee
- Benzimidazoles/administration & dosage
- Benzimidazoles/adverse effects
- Benzimidazoles/pharmacology
- Benzimidazoles/therapeutic use
- Blood Coagulation Tests
- Clinical Trials, Phase III as Topic
- Contraindications
- Dabigatran
- Drug Administration Schedule
- Drug Interactions
- Drug Monitoring
- Hematoma, Epidural, Spinal/chemically induced
- Hematoma, Epidural, Spinal/prevention & control
- Humans
- Morpholines/administration & dosage
- Morpholines/adverse effects
- Morpholines/pharmacology
- Morpholines/therapeutic use
- Platelet Aggregation Inhibitors/adverse effects
- Platelet Aggregation Inhibitors/pharmacology
- Platelet Aggregation Inhibitors/therapeutic use
- Postoperative Complications/prevention & control
- Postoperative Hemorrhage/chemically induced
- Postoperative Hemorrhage/prevention & control
- Postoperative Nausea and Vomiting/chemically induced
- Practice Guidelines as Topic
- Pyrazoles/administration & dosage
- Pyrazoles/adverse effects
- Pyrazoles/pharmacology
- Pyrazoles/therapeutic use
- Pyridines/administration & dosage
- Pyridines/adverse effects
- Pyridines/pharmacology
- Pyridines/therapeutic use
- Pyridones/administration & dosage
- Pyridones/adverse effects
- Pyridones/pharmacology
- Pyridones/therapeutic use
- Rivaroxaban
- Thiophenes/administration & dosage
- Thiophenes/adverse effects
- Thiophenes/pharmacology
- Thiophenes/therapeutic use
- Venous Thromboembolism/prevention & control
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Affiliation(s)
- W Klauser
- Orthopaedic Department, Helios ENDO Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany,
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43
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Benzon H, Avram M, Green D, Bonow R. New oral anticoagulants and regional anaesthesia. Br J Anaesth 2013; 111 Suppl 1:i96-113. [DOI: 10.1093/bja/aet401] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Al Khudairy A, Al-Hadeedi O, Sayana MK, Galvin R, Quinlan JF. Withholding clopidogrel for 3 to 6 versus 7 days or more before surgery in hip fracture patients. J Orthop Surg (Hong Kong) 2013; 21:146-50. [PMID: 24014772 DOI: 10.1177/230949901302100205] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE. To compare morbidity and mortality after hip fracture surgery in patients withholding clopidogrel for 3 to 6 days versus ≥7 days or more. METHODS. Records of 16 men and 31 women aged 49 to 92 (mean, 80.2) years who underwent hip fracture surgery after withholding clopidogrel for 3 to 6 days (n=24) versus ≥7 days or more (n=23) were compared. The patients were taking clopidogrel owing to ischaemic heart disease (n=37), cerebrovascular disease (n=7), and intolerance to aspirin (n=3). Patient demographics, American Society of Anesthesiologists status, preoperative delay, length of hospital stay, perioperative haemoglobin reduction, receipt of blood and platelet transfusions, morbidity, and mortality were recorded. RESULTS. Respectively in the early-surgery and delayed-surgery groups, the mean surgical delay was 4.2 and 8.0 days, the mean length of hospital stay was 21.1 and 28.7 days, the mean peri-operative haemoglobin reduction was 1.5 and 1.1 g/dl, the mean units of blood transfusion per patient was 0.8 and 0.7. No severe intra-operative bleeding or wound haematoma was encountered in either group. Two patients in each group died within one month, and 2 more in the delayed-surgery group died within 3 months. The main cause of death was cardiovascular. CONCLUSION. Withholding clopidogrel for <7 days before surgery conferred no increased risk in hip fracture patients.
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Levy JH, Faraoni D, Spring JL, Douketis JD, Samama CM. Managing New Oral Anticoagulants in the Perioperative and Intensive Care Unit Setting. Anesthesiology 2013; 118:1466-74. [DOI: 10.1097/aln.0b013e318289bcba] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Managing patients in the perioperative setting receiving novel oral anticoagulation agents for thromboprophylaxis or stroke prevention with atrial fibrillation is an important consideration for clinicians. The novel oral anticoagulation agents include direct Factor Xa inhibitors rivaroxaban and apixaban, and the direct thrombin inhibitor dabigatran. In elective surgery, discontinuing their use is important, but renal function must also be considered because elimination is highly dependent on renal elimination. If bleeding occurs in patients who have received these agents, common principles of bleeding management as with any anticoagulant (including the known principles for warfarin) should be considered. This review summarizes the available data regarding the management of bleeding with novel oral anticoagulation agents. Hemodialysis is a therapeutic option for dabigatran-related bleeding, while in vitro studies showed that prothrombin complex concentrates are reported to be useful for rivaroxaban-related bleeding. Additional clinical studies are needed to determine the best method for reversal of the novel oral anticoagulation agents when bleeding occurs.
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Affiliation(s)
- Jerrold H. Levy
- Professor, Department of Anesthesiology/Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - David Faraoni
- Assistant Professor, Queen Fabiola Children’s University Hospital, Brussels, Belgium
| | - Jenna L. Spring
- Medical Student, Emory University School of Medicine, Atlanta, Georgia
| | - James D. Douketis
- Professor of Medicine, Division of Hematology and Thromboembolism, McMaster University, Hamilton, Ontario, Canada
| | - Charles M. Samama
- Professor, Department of Anesthesiology and Intensive Care, Hotel-Dieu University Hospital, Paris, France
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ROSENCHER N, LLAU JV, MUECK W, LOEWE A, BERKOWITZ SD, HOMERING M. Incidence of neuraxial haematoma after total hip or knee surgery: RECORD programme (rivaroxaban vs. enoxaparin). Acta Anaesthesiol Scand 2013; 57:565-72. [PMID: 23336294 DOI: 10.1111/aas.12069] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients receiving anticoagulants could be at higher risk of compressive haematoma with neuraxial anaesthesia use. The phase III RECORD programme compared rivaroxaban with enoxaparin for prevention of venous thromboembolism after total hip or knee replacement surgery in more than 12,500 patients. This observational analysis evaluated the risk of neuraxial haematoma after neuraxial anaesthesia in patients receiving rivaroxaban or enoxaparin using pooled RECORD1-4 data. METHODS The incidences of intraspinal bleeding or haemorrhagic puncture were recorded as part of the criteria for major bleeding (the primary safety outcome in the RECORD studies). Incidences of allogeneic transfusion and venous thromboembolism by type of anaesthesia were also recorded. RESULTS No compressive haematomas occurred in rivaroxaban-treated patients (10 mg once daily started 6-8 h after surgery) who underwent neuraxial anaesthesia (n = 4086). Among enoxaparin-treated patients (n = 4090), one compressive spinal haematoma requiring laminectomy occurred after epidural catheter removal in an elderly female patient with renal insufficiency undergoing total knee replacement. Total venous thromboembolism rates did not differ according to type of anaesthesia. CONCLUSION Although no issues were observed with the use of neuraxial anaesthesia in this population of 4086 patients receiving rivaroxaban after total hip or knee replacement, it is important to remain aware of the risk of compressive haematoma. This may be of particular concern in elderly patients with renal insufficiency receiving an anticoagulant predominantly eliminated via the kidneys.
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Affiliation(s)
| | - J. V. LLAU
- Hospital Clínico Universitario; Valencia; Spain
| | - W. MUECK
- Clinical Pharmacokinetics; Bayer HealthCare; Wuppertal; Germany
| | - A. LOEWE
- Global Medical Affairs; Bayer HealthCare; Berlin; Germany
| | - S. D. BERKOWITZ
- Global Clinical Development; Bayer HealthCare Pharmaceuticals; Montville; NJ; USA
| | - M. HOMERING
- Global Clinical Development; Bayer HealthCare; Wuppertal; Germany
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Palareti G, Ageno W, Ferrari A, Filippi A, Imberti D, Pengo V, Rubboli A, Toni D. Clinical management of rivaroxaban-treated patients. Expert Opin Pharmacother 2013; 14:655-67. [DOI: 10.1517/14656566.2013.773310] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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48
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Koscielny J, Rutkauskaite E. Präinterventionelle Änderung der Gerinnungsmedikation. VISZERALMEDIZIN 2013. [DOI: 10.1159/000355383] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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49
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Rosencher N, Noack H, Feuring M, Clemens A, Friedman RJ, Eriksson BI. Type of anaesthesia and the safety and efficacy of thromboprophylaxis with enoxaparin or dabigatran etexilate in major orthopaedic surgery: pooled analysis of three randomized controlled trials. Thromb J 2012; 10:9. [PMID: 22709460 PMCID: PMC3444414 DOI: 10.1186/1477-9560-10-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/31/2012] [Indexed: 12/02/2022] Open
Abstract
Background There has been a shift towards greater use of neuraxial over general anaesthesia for patients undergoing total hip or knee arthroplasty. Furthermore, suggestions that peripheral nerve block may reduce adverse effects have recently been put forward. Although older studies showed a reduction in venous thromboembolism (VTE) with neuraxial compared with general anaesthesia, this difference has not been confirmed in studies using effective current thromboprophylaxis. We used a large data set to investigate the pattern of anaesthesia usage, and whether anaesthesia type affects efficacy and bleeding outcomes of thromboprophylaxis overall, within each treatment group, or for the novel oral anticoagulant dabigatran etexilate versus enoxaparin. Methods Three previously reported trials compared 220 mg and 150 mg dabigatran etexilate once daily with enoxaparin after knee or hip arthroplasty. A pooled analysis was performed in patients receiving general or neuraxial anaesthesia, or the combination of either with peripheral nerve block (n = 8062). Outcome measures were major VTE plus VTE-related mortality, major bleeding and major plus clinically relevant bleeding events. Results General, neuraxial and combination anaesthesia were used in 29%, 52% and 19% of patients, respectively. Differences in efficacy and safety between anaesthesia subgroups were small and not significant, except for a slightly higher rate of major VTE and VTE-related mortality with general versus neuraxial anaesthesia (odds ratio: 1.40; 95% confidence interval: 1.03–1.90; p = 0.035) in the overall population. There were no significant effects of anaesthesia type on efficacy or safety of dabigatran etexilate versus enoxaparin. Conclusions Anaesthesia type did not greatly affect efficacy and safety outcomes in the pooled population of all three treatment groups. The efficacy and safety of dabigatran etexilate was comparable with enoxaparin, regardless of type of anaesthesia. Trial registration ClinicalTrials.gov identifiers: NCT00168805, NCT00168818, NCT00152971.
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Affiliation(s)
- Nadia Rosencher
- Staff Anaesthesiologist, Department of Anaesthesiology and Intensive Care, Paris Descartes University, Cochin Hospital (AP HP), rue du Faubourg Saint-Jacques, 75014, Paris, France.
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Llau JV, Ferrandis R, Castillo J, de Andrés J, Gomar C, Gómez-Luque A, Hidalgo F, Torres LM. [Management of direct action oral anticoagulants in the peri-operative period and invasive techniques]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:321-330. [PMID: 22633209 DOI: 10.1016/j.redar.2012.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 01/23/2012] [Indexed: 06/01/2023]
Abstract
The new direct-acting oral anticoagulants (ACOD) in patients on prolonged treatment require the need to balance the risk of haemorrhage by administering them against the risk of thrombosis on withdrawing them. Recommendations for their management are proposed in the present article: A) Thromboprophylaxis and general anaesthesia: the performing of regional anaesthesia if administered with an ACOD as thromboprophylaxis requires some safety intervals based on their pharmacokinetic parameters; B) Management of ACOD in elective surgery: in patients with normal renal function and a low haemorrhage/thrombosis risk, stop the ACOD two days before the surgery; it the haemorrhage/thrombosis risk is high and/or renal function is impaired, therapy with a low molecular weight heparin is proposed from 5 days prior to the surgery, and C) Management of ACOD in urgent surgery and associated haemorrhage: the systematic prophylactic administration of haemostatics is recommended. In the event of acute bleeding that may place the life of the patient at risk (due to volume or location), the administration of concentrated prothrombin complex, fresh plasma, or factor VIIa, must be assessed, together with general control measures of acute haemorrhage. These recommendations should be considered in the context of the use drugs that do have a specific antidote, where their monitoring by the usual coagulation tests is not routine, and with those in which there is limited experience. We believe they need to be reviewed in the future, depending on further studies and clinical experience obtained.
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Affiliation(s)
- J V Llau
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario de Valencia, Universidad Católica «San Vicente Mártir», Valencia, España
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