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Power SJ, Stewart KE, Tanaka KA, Butt AL. In response: Caution in prediction: Evaluating Zhang et al.'s approach to red blood cell transfusion risk. Transfusion 2024; 64:560-561. [PMID: 38488273 DOI: 10.1111/trf.17731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 11/18/2023] [Accepted: 12/07/2023] [Indexed: 03/19/2024]
Affiliation(s)
- Sarah J Power
- College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kenneth E Stewart
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amir L Butt
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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2
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von Heymann C, Unverdorben M, Colonna P, Santamaria A, Saxena M, Vanassche T, Köhler S, Borrow AP, Jin J, Chen C. Management of edoxaban therapy and clinical outcomes in patients undergoing major or nonmajor surgery: a subanalysis of the EMIT-AF/VTE study. Thromb J 2023; 21:124. [PMID: 38098072 PMCID: PMC10722787 DOI: 10.1186/s12959-023-00568-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/24/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Optimising periprocedural management of direct oral anticoagulation in patients with atrial fibrillation on chronic treatment undergoing major surgeries is an important aspect of balancing the risk of surgery-related bleeding with the risk of thromboembolic events, which may vary by surgery type. METHODS This subanalysis of the prospective EMIT-AF/VTE programme assessed periprocedural-edoxaban management, according to physicians' decisions, and bleeding and thromboembolic event rates in patients who underwent major vs. nonmajor surgeries. Edoxaban interruption and clinical outcomes were compared between major vs. nonmajor surgeries and between renal function subgroups (creatinine clearance [CrCL] ≤ 50 mL/min vs. > 50 mL/min). RESULTS We included 276 major and 512 nonmajor surgeries. The median pre- and postprocedural duration of edoxaban interruption in major vs. nonmajor surgeries was 4 vs. 1 days, whereas median duration of interruption for those with preprocedural-only and postprocedural-only interruption was 2 vs. 1 days and 2 vs. 0 days, respectively (P < 0.0001). Rates of all bleeding and clinically relevant nonmajor bleeding were numerically higher in major vs. nonmajor surgeries. Event rates (number of events per 100 surgeries) were low overall (< 6 events per 100 surgeries), independent of renal function subgroups. CONCLUSION In this subanalysis of the EMIT-AF/VTE programme, periprocedural-edoxaban interruption was significantly longer in patients undergoing major vs. nonmajor surgery. This clinician-driven approach was associated with low rates of bleeding and thromboembolic events following both major and nonmajor surgeries. TRIAL REGISTRATION NCT02950168, registered October 31, 2016; NCT02951039, registered November 1, 2016.
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Affiliation(s)
- Christian von Heymann
- Department of Anaesthesia & Intensive Care Medicine, Emergency Medicine, and Pain Therapy, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, Berlin, 10249, Germany.
| | | | - Paolo Colonna
- Polyclinic of Bari - Hospital, Department of Cardiology, Bari, Italy
| | | | - Manish Saxena
- Barts NIHR Cardiovascular Biomedical Research Centre, London, UK
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University Hospitals (UZ) Leuven, Leuven, Belgium
| | | | | | - James Jin
- Daiichi Sankyo, Inc, Basking Ridge, NJ, USA
| | - Cathy Chen
- Daiichi Sankyo, Inc, Basking Ridge, NJ, USA
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3
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Riahi N, Rozen L, Demulder A. Usefullness of Heparin Calibrated Anti-Xa Activity to Assess Anticoagulant Activity of Apixaban and Rivaroxaban in Emergency Patients Scheduled for Acute Interventions. J Clin Med 2023; 12:6785. [PMID: 37959250 PMCID: PMC10647510 DOI: 10.3390/jcm12216785] [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: 09/05/2023] [Revised: 10/16/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
(1) Background: Direct oral anticoagulants (DOACs) require monitoring in some critical clinical situations. The specific tests for DOAC monitoring are not yet available in all labs. The aim of this study was to evaluate if a unique, more widespread heparin-calibrated anti-Xa assay could be suitable to estimate the concentrations of apixaban and rivaroxaban in order to establish an algorithm helping our clinicians in their therapeutic decision for patients treated with DOACs in emergencies. (2) Methods: A first retrospective part allowed us to determine of a conversion factor between the measured DOAC concentration and the deducted anti-Xa heparin activity based on optic density. During the second prospective part, both DOAC concentration (ng/mL) and anti-Xa activity heparin (UI/mL) were measured on the same sample, and the previously determined conversion factor was applied to each UI/mL value. We then compared the calculated and measured DOAC concentration values. (3) Results: The analysis of the derivation cohort confirmed a good correlation, especially between the anti-Xa heparin activity and the apixaban concentrations (r = 0.97). Additionally, we determined heparin-calibrated anti-Xa assay cut-offs for invasive procedures at 0.3 UI/mL and for intravenous thrombolysis at 0.51 UI/mL using ROC curves with a sensitivity at 98% and specificity at 95% for 0.3 UI/mL and a sensitivity at 97.7% and specificity at 88.2% for the cut-off of 0.51 UI/mL. In the validation cohort, we confirmed the agreement between measured and calculated DOAC concentrations for the low values, especially around cut-offs with an excellent negative predictive value for 0.51 UI/mL (94% for apixaban and 100% for rivaroxaban) and a good negative predictive value for 0.3 UI/mL (83.3% for apixaban and 85.7% for rivaroxaban). (4) Conclusions: Our results confirm that it is possible to correctly predict or exclude the presence of apixaban/rivaroxaban in emergency situations when specific tests are not readily available.
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Affiliation(s)
- Nada Riahi
- Department of Hematology, Laboratoire Hospitalier Universitaire de Bruxelles LHUB-ULB, Université Libre de Bruxelles ULB, 1020 Brussels, Belgium; (N.R.); (A.D.)
| | - Laurence Rozen
- Department of Hematology, Laboratoire Hospitalier Universitaire de Bruxelles LHUB-ULB, Université Libre de Bruxelles ULB, 1020 Brussels, Belgium; (N.R.); (A.D.)
- Laboratory of Hematology, CHU-Brugmann, 1020 Brussels, Belgium
| | - Anne Demulder
- Department of Hematology, Laboratoire Hospitalier Universitaire de Bruxelles LHUB-ULB, Université Libre de Bruxelles ULB, 1020 Brussels, Belgium; (N.R.); (A.D.)
- Laboratory of Hematology, CHU-Brugmann, 1020 Brussels, Belgium
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4
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Botrel T, Cunat S, Helms J, Lemarié J, Gaillon J, Préau S, Favory R, Thille AW, Boissier F, Maury E, Joffre J, Ait-Oufella H. Extracranial anticoagulant related bleedings admitted to intensive care units: a French multicenter retrospective study. Crit Care 2023; 27:312. [PMID: 37559102 PMCID: PMC10411017 DOI: 10.1186/s13054-023-04605-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/07/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Anticoagulants are widely used but can lead to iatrogenic events such as bleeding. Limited data exists regarding the characteristics and management of patients admitted to intensive care units (ICU) for severe anticoagulant-related extracranial bleeding. METHODS A retrospective observational study was conducted in five French ICUs. From January 2007 to December 2018, all patients aged over 18 years admitted to ICU for extracranial bleeding while receiving therapeutic anticoagulation were included. RESULTS 486 patients were included, mainly male (61%) with an average age of 73 ± 13 years. Most patients had comorbidities, including hypertension (68%), heart disease (49%) and diabetes (33%). Patients were treated by vitamin K antagonists (VKA, 54%), heparins (25%) and direct oral anticoagulants (DOAC, 7%). The incidence of patients admitted to ICU for anticoagulant-related bleeding increased from 3.2/1000 admissions in 2007 to 5.8/1000 in 2018. This increase was particularly high for DOAC class. Upon admission, patients exhibited severe organ failure, as evidenced by a high SOFA score (7 ± 4) and requirement for organ support therapies such as vasopressors (31.5%) and invasive mechanical ventilation (34%). Adherence to guidelines for the specific treatment of anticoagulant-related bleeding was generally low. ICU mortality was 27%. In multivariate analysis, five factors were independently associated with mortality: chronic hypertension, need for vasopressors, impaired consciousness, hyperlactatemia and prolonged aPTT > 1.2. CONCLUSION Anticoagulant-related extracranial bleeding requiring ICU admission is a serious complication responsible for organ failure and significant mortality. Its incidence is rising. The therapeutic management is suboptimal and could be improved by educational programs.
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Affiliation(s)
- Thomas Botrel
- Medical Intensive Care Unit, Intensive Care Department, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Sibylle Cunat
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Strasbourg, France
| | - Julie Helms
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Jérémie Lemarié
- Intensive Care Department, Nantes University Hospital, Nantes, France
| | - Jeanne Gaillon
- Intensive Care Department, Nantes University Hospital, Nantes, France
| | - Sébastien Préau
- Intensive Care Department, CHU Lille, Univ. Lille, RID-AGE, INSERM UMR 1167, Institut Pasteur, 59000, Lille, France
| | - Raphael Favory
- Intensive Care Department, CHU Lille, Univ. Lille, RID-AGE, INSERM UMR 1167, Institut Pasteur, 59000, Lille, France
| | - Arnaud W Thille
- Intensive Care Department, Centre Hospitalo-Universitaire de Poitiers, Poitiers, France
- INSERM CIC 1402 (IS-ALIVE Group), Université de Poitiers, Poitiers, France
| | - Florence Boissier
- Intensive Care Department, Centre Hospitalo-Universitaire de Poitiers, Poitiers, France
- INSERM CIC 1402 (IS-ALIVE Group), Université de Poitiers, Poitiers, France
| | - Eric Maury
- Medical Intensive Care Unit, Intensive Care Department, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
- Sorbonne Université, Paris, France
| | - Jérémie Joffre
- Medical Intensive Care Unit, Intensive Care Department, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
- Sorbonne Université, Paris, France
- Centre de Recherche Saint-Antoine Inserm UMR-S 938, Paris, France
| | - Hafid Ait-Oufella
- Medical Intensive Care Unit, Intensive Care Department, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France.
- Centre de Recherche Saint-Antoine Inserm UMR-S 938, Paris, France.
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5
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Zeng G, Zhong W, Chaussy CG, Tiselius HG, Xu C, Turney B, Turk C, Tailly GG, Preminger GM, Akpinar H, Petrik A, Bernardo N, Wiseman O, Farahat Y, Budia A, Jones DK, Beltran Suarez E, De Marco F, Mazzon G, Lv J, Natchagande G, Guven S, Ibrahim TAA, Xu H, Xie L, Ye Z, Sarica K. International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy. Eur Urol Focus 2023; 9:513-523. [PMID: 36435718 DOI: 10.1016/j.euf.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/04/2022] [Accepted: 11/08/2022] [Indexed: 11/24/2022]
Abstract
Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.
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Affiliation(s)
- Guohua Zeng
- Department of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangdong Key Laboratory of Urology, Guangzhou, China.
| | - Wen Zhong
- Department of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangdong Key Laboratory of Urology, Guangzhou, China
| | - Christian G Chaussy
- University of Munich, Munich, Germany; University of Regensburg, Regensburg, Germany
| | - Hans Göran Tiselius
- Division of Urology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Changbao Xu
- The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ben Turney
- Department of Urology, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Christian Turk
- Department of Urology, Hospital of the Sisters of Charity, Vienna, Austria
| | | | - Glenn M Preminger
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Haluk Akpinar
- Department of Urology, Florence Nightingale Hospitals Group, Istanbul, Turkey
| | - Ales Petrik
- Department of Urology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Norberto Bernardo
- Department of Urology, Hospital de Clinicas Jose de San Martin, Buenos Aires, Argentina
| | - Oliver Wiseman
- Department of Urology, Cambridge University Hospitals, Cambridge, UK
| | - Yasser Farahat
- Department of Urology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Alberto Budia
- Department of Urology, La Fe Polytechnic University Hospital, Valencia, Spain
| | - David K Jones
- Department of Pharmacology, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Edgar Beltran Suarez
- Department of Urology, Specialty Hospital La Raza, National Medical Center of the Mexican Institute of Social Security, Mexico City, Mexico
| | - Ferdinando De Marco
- Urology Division, Istituto Neurotraumatologico Italiano-Grottaferrata, Rome, Italy
| | - Giorgio Mazzon
- Department of Urology, San Bassiano Hospital, Vicenza, Italy
| | - Jianlin Lv
- Department of Urology, Jiangning Hospital, Nanjing Medical University, Nanjing, China
| | | | - Selcuk Guven
- Urology Department, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | | | - Hanfeng Xu
- Department of Urology, First Affiliated Hospital of University of South China, Henyang, China
| | - Lei Xie
- Department of Urology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Zhangqun Ye
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kemal Sarica
- Department of Urology, Biruni University Medical School, Istanbul, Turkey.
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6
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Zeng G, Zhong W, Mazzon G, Choong S, Pearle M, Agrawal M, Scoffone CM, Fiori C, Gökce MI, Lam W, Petkova K, Sabuncu K, Gadzhiev N, Pietropaolo A, Emiliani E, Sarica K. International Alliance of Urolithiasis (IAU) Guideline on percutaneous nephrolithotomy. Minerva Urol Nephrol 2022; 74:653-668. [PMID: 35099162 DOI: 10.23736/s2724-6051.22.04752-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The International Alliance of Urolithiasis (IAU) would like to release the latest guideline on percutaneous nephrolithotomy (PCNL) and to provide a clinical framework for surgeons performing PCNLs. These recommendations were collected and appraised from a systematic review and assessment of the literature covering all aspects of PCNLs from the PubMed database between January 1, 1976, and July 31, 2021. Each generated recommendation was graded using a modified GRADE methodology. The quality of the evidence was graded using a classification system modified from the Oxford Center for Evidence-Based Medicine Levels of Evidence. Forty-seven recommendations were summarized and graded, which covered the following issues, indications and contraindications, stone complexity evaluation, preoperative imaging, antibiotic strategy, management of antithrombotic therapy, anesthesia, position, puncture, tracts, dilation, lithotripsy, intraoperative evaluation of residual stones, exit strategy, postoperative imaging and stone-free status evaluation, complications. The present guideline on PCNL was the first in the IAU series of urolithiasis management guidelines. The recommendations, tips and tricks across the PCNL procedures would provide adequate guidance for urologists performing PCNLs to ensure safety and efficiency in PCNLs.
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Affiliation(s)
- Guohua Zeng
- Department of Urology, Guangdong Key Laboratory of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wen Zhong
- Department of Urology, Guangdong Key Laboratory of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Giorgio Mazzon
- Department of Urology, San Bassiano Hospital, Vicenza, Italy
| | - Simon Choong
- University College Hospital of London, Institute of Urology, London, UK
| | - Margaret Pearle
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Madhu Agrawal
- Department of Urology, Center for Minimally Invasive Endourology, Global Rainbow Healthcare, Agra, India
| | | | - Cristian Fiori
- Department of Urology, San Luigi Hospital, University of Turin, Turin, Italy
| | - Mehmet I Gökce
- Department of Urology, Faculty of Medicine, University of Ankara, Ankara, Turkey
| | - Wayne Lam
- Division of Urology, Queen Mary Hospital, Hong Kong, China
| | - Kremena Petkova
- Military Medical Academy, Department of Urology and Nephrology, Sofia, Bulgaria
| | - Kubilay Sabuncu
- Department of Urology, Karacabey State Hospital, Karacabey-Bursa, Turkey
| | - Nariman Gadzhiev
- Department of Urology, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - Amelia Pietropaolo
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Esteban Emiliani
- Department of Urology, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Kemal Sarica
- Medical School, Department of Urology, Biruni University, Istanbul, Turkey -
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Barletta JF, Erstad BL. Dosing Medications for Coagulopathy Reversal in Patients with Extreme Obesity. J Emerg Med 2022; 63:541-550. [PMID: 35906122 DOI: 10.1016/j.jemermed.2022.04.036] [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: 02/17/2022] [Revised: 03/22/2022] [Accepted: 04/23/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND The reversal of anticoagulant or antiplatelet medications is a priority in the management of patients with severe injury with the goal of minimizing further bleeding without thrombotic complications. There are few studies, however, evaluating the dosing of reversal agents in the setting of trauma specific to patients with extreme obesity. Nevertheless, clinicians must still make decisions, balancing concerns of ongoing bleeding with excessive thrombosis. OBJECTIVES We describe the literature pertaining to dosing of medications used for the reversal of both drug-induced and trauma-related coagulopathy with the intent of providing a framework for clinicians to make dosing decisions in this challenging population. DISCUSSION Obesity is known to impact both the volume of distribution and the clearance of medications, but these changes are not usually linear with size nor are they uniform across drugs. Current strategies for dosing reversal agents in obesity include a capped dose (e.g., prothrombin complex concentrates), fixed dosages (e.g., andexanet alfa, idarucizumab, and tranexamic acid), and weight-based dosing (e.g., desmopressin). Extreme obesity, however, was not highly prevalent in the studies that have validated these dosing strategies. In fact, many of the clinical studies fail to report the average weight of the patients included. CONCLUSION Future studies should make efforts to increase reporting of patients with obesity included in clinical trials along with results stratified by weight class. In the meantime, doses listed in product labels should be used. Desmopressin should be dosed using either ideal body weight or a dose-capping strategy.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
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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: 90] [Impact Index Per Article: 45.0] [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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9
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Heparin Anti-Xa Activity, a Readily Available Unique Test to Quantify Apixaban, Rivaroxaban, Fondaparinux, and Danaparoid Levels. Anesth Analg 2021; 132:707-716. [PMID: 32833716 DOI: 10.1213/ane.0000000000005114] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Despite their usefulness in perioperative and acute care settings, factor-Xa inhibitor-specific assays are scarcely available, contrary to heparin anti-Xa assay. We assessed whether the heparin anti-Xa assay can (1) be used as a screening test to rule out apixaban, rivaroxaban, fondaparinux, and danaparoid levels that contraindicate invasive procedures according to current guidelines (>30 ng·mL-1, >30 ng·mL-1, >0.1 µg·mL-1, and >0.1 IU·mL-1, respectively), (2) quantify the anticoagulant level if found significant, that is, if it exceeded the abovementioned threshold. METHODS In the derivation cohort then in the validation cohort, via receiver operating characteristics (ROC) curve analysis, we evaluated the ability of heparin anti-Xa assay to detect levels of factor-Xa inhibitors above or below the abovementioned safety thresholds recommended for an invasive procedure (screening test). Among samples with relevant levels of factor-Xa inhibitor, we determined the conversion factor linking the measured level and heparin anti-Xa activity in a derivation cohort. In a validation cohort, the estimated level of each factor-Xa inhibitor was thus inferred from heparin anti-Xa activity. The agreement between measured and estimated levels of factor-Xa inhibitors was assessed. RESULTS Among 989 (355 patients) and 756 blood samples (420 patients) in the derivation and validation cohort, there was a strong linear relationship between heparin anti-Xa activities and factor-Xa inhibitors measured level (r = 0.99 [95% confidence interval {CI}, 0.99-0.99]). In the derivation cohort, heparin anti-Xa activity ≤0.2, ≤0.3, <0.1, <0.1 IU·mL-1 reliably ruled out a relevant level of apixaban, rivaroxaban, fondaparinux, and danaparoid, respectively (area under the ROC curve ≥0.99). In the validation cohort, these cutoffs yielded excellent classification accuracy (≥96%). If this screening test indicated relevant level of factor-Xa inhibitor, estimated and measured levels closely agreed (Lin's correlation coefficient close to its maximal value: 95% CI, 0.99-0.99). More than 96% of the estimated levels fell into the predefined range of acceptability (ie, 80%-120% of the measured level). CONCLUSIONS A unique simple test already widely used to assay heparin was also useful for quantifying these 4 other anticoagulants. Both clinical and economic impacts of these findings should be assessed in a specific study.
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10
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Renon F, Rago A, Liccardo B, D'Andrea A, Riegler L, Golino P, Nigro G, Russo V. Direct Oral Anticoagulants Plasma Levels Measurement: Clinical Usefulness from Trials and Real-World Data. Semin Thromb Hemost 2021; 47:150-160. [PMID: 33636746 DOI: 10.1055/s-0041-1723770] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Measurement of direct oral anticoagulants (DOACs) activity is not routinely necessary. Indeed, evaluation of DOACs plasmatic concentration is discouraged for the majority of patients, due to the lack of outcome data supporting this approach. Nevertheless, DOAC measurements may be useful in emergency situations such as serious bleeding events, need for urgent invasive procedures, and acute ischemic stroke or in managing anticoagulation in "special populations" not adequately studied in clinical trials, for example the very elderly or those at the extremes of body weight. The aim of this review is to describe and summarize the methods for DOACs activity evaluation and the settings in which their plasma level measurement may be indicated, analyzing indications from scientific societies and evidence from clinical trials, as well as real world data on the usefulness of DOACs plasma levels "monitoring."
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Affiliation(s)
- Francesca Renon
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | | | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Lucia Riegler
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Paolo Golino
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Vincenzo Russo
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
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11
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Paul C, Baby M, Anthraper AR, K K. NOACs: an emerging class of oral anticoagulants-a review article. FUTURE JOURNAL OF PHARMACEUTICAL SCIENCES 2020. [DOI: 10.1186/s43094-020-00114-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AbstractBackgroundNOACs, commonly known as novel oral anticoagulants, are the non-vitamin K antagonist oral anticoagulants which are relatively newer in the market. It has displaced vitamin K antagonists, notably warfarin, for many indications. These agents are dabigatran, rivaroxaban, apixaban, and edoxaban.Main bodyThe drugs are licenced to prevent stroke and also systemic embolism in patients on treatment for atrial fibrillation and prevent venous thromboembolism. Rivaroxaban and apixaban are approved for prophylaxis of thrombus following surgical hip or knee arthroplasty. The recent surveys reveal that use of NOACs has steeply increased due to its safety profile and convenience to use. Also, the studies have shown that NOACs have lesser bleeding complications and associated mortality in contrast to traditional anticoagulants. The upcoming years are known to be NOACs’ age due to the significant findings in this area.ConclusionTherefore, a basic understanding on these drugs is highly recommended to provide a better service to the patients. This article aims to provide quick and brief information on the novel class of drugs. It equips an overview of NOAC and deals with the following areas: (i) pharmacology, (ii) laboratory methods, (iii) peri-operative management, (iv) advantages, (v) challenges, and (vi) future.
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12
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Evrard J, Hardy M, Dogné JM, Lessire S, Maloteau V, Mullier F, Douxfils J. Are the DOAC plasma level thresholds appropriate for clinical decision-making? A reappraisal using thrombin generation testing. Int J Lab Hematol 2020; 43:e48-e51. [PMID: 33037773 DOI: 10.1111/ijlh.13356] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/04/2020] [Accepted: 09/05/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Jonathan Evrard
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Michaël Hardy
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, Yvoir, Belgium.,Hematology Laboratory, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Namur Biobank-eXchange (NAB-X), University of Namur, Namur, Belgium
| | - Sarah Lessire
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, Yvoir, Belgium
| | - Vincent Maloteau
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, Yvoir, Belgium
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
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13
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Milling TJ, Pollack CV. A review of guidelines on anticoagulation reversal across different clinical scenarios – Is there a general consensus? Am J Emerg Med 2020; 38:1890-1903. [PMID: 32750627 PMCID: PMC9245126 DOI: 10.1016/j.ajem.2020.05.086] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/13/2020] [Accepted: 05/22/2020] [Indexed: 12/23/2022] Open
Affiliation(s)
- Truman J Milling
- Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX, USA; Department of Neurology, Seton Dell Medical School Stroke Institute, Austin, TX, USA
| | - Charles V Pollack
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
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14
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Creeper K, Stafford A, Reynolds S, Samida S, P'Ng S, Glennon D, Seymour H, Grove C. Outcomes and anticoagulation use for elderly patients that present with an Acute Hip Fracture: multi‐centre, retrospective analysis. Intern Med J 2020; 52:418-425. [DOI: 10.1111/imj.15007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/15/2020] [Accepted: 08/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Katherine Creeper
- Haematology Department, NedlandsSir Charles Gairdner Hospital Western Australia
- PathWest Laboratory Medicine, Nedlands Western Australia
| | - Andrew Stafford
- School of Pharmacy and Biomedical SciencesCurtin University of Technology Bentley Western Australia
| | - Sophie Reynolds
- Royal Perth Hospital Department of Geriatric Medicine Perth Western Australia
| | - Sapna Samida
- Royal Perth Hospital Department of Geriatric Medicine Perth Western Australia
| | - Stephanie P'Ng
- PathWest Laboratory Medicine, Nedlands Western Australia
- Department of HaematologyFiona Stanley Hospital Murdoch Western Australia
| | - Denise Glennon
- Department of Rehabilitation and Aged CareSir Charles Gairdner Hospital Nedlands Western Australia
| | - Hannah Seymour
- Department of Geriatrics and Aged CareFiona Stanley Hospital Murdoch Western Australia
| | - Carolyn Grove
- Haematology Department, NedlandsSir Charles Gairdner Hospital Western Australia
- PathWest Laboratory Medicine, Nedlands Western Australia
- School of Medicine and PharmacologyUniversity of Western Australia Nedlands Western Australia
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15
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Imamura H, Minami S, Isagawa Y, Morita M, Hirabaru M, Kawahara D, Tokai H, Noda K, Inoue K, Haraguchi M, Eguchi S. The impact of antithrombotic therapy in patients undergoing emergency laparoscopic cholecystectomy for acute cholecystitis - A single center experience. Asian J Endosc Surg 2020; 13:359-365. [PMID: 31430063 DOI: 10.1111/ases.12751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/22/2019] [Accepted: 07/31/2019] [Indexed: 12/12/2022]
Abstract
AIM The risk of developing hemorrhagic complications during or after surgery in patients receiving antithrombotic therapy remains uncertain. Moreover, the impact of antithrombotic therapy under an acute inflammatory status is unclear. We investigated the impact of antithrombotic therapy in patients undergoing emergency laparoscopic cholecystectomy for acute cholecystitis. METHODS This record-based retrospective study included patients who underwent emergency laparoscopic cholecystectomy for acute cholecystitis between September 2015 and January 2019. Patients who received elective laparoscopic cholecystectomy, open cholecystectomy, or gallbladder drainage before surgery were excluded. We evaluated the diseases for which antithrombotic therapy was administered, background characteristics, laboratory parameters and perioperative outcomes of patients with acute cholecystitis. The primary outcomes were intraoperative bleeding, blood transfusion requirement, conversion to an open procedure, and postoperative complications, including bleeding. RESULTS One hundred and twenty-one patients (non-antithrombotic therapy, n = 92; antithrombotic therapy, n = 29) were analyzed. There were differences in age and American Association of Anesthesiologists class (P < .05), but not in the grade of acute cholecystitis (P = .19). There were no differences in the operation time (non-antithrombotic vs antithrombotic therapy: 142 [58-313] vs 146 minutes [65-373], P = .85), bleeding (17.5 mL [1-1400] vs 25 mL [1-1337], P = .58), blood transfusion requirement (n = 3 [3.2%] vs n = 2 [6.9%], P = .59) and the number of cases converted to open surgery (n = 8 [9%] vs n = 2 [7%], P = 1). The rates of postoperative complications, including bleeding, did not differ between the two groups and there was no mortality in either group. CONCLUSION Emergency laparoscopic cholecystectomy could be planned for patients receiving single antithrombotic therapy, similar to patients who were not receiving antithrombotic therapy.
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Affiliation(s)
- Hajime Imamura
- Department of Surgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Shigeki Minami
- Department of Surgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Yuriko Isagawa
- Department of Surgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Michi Morita
- Department of Surgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Masataka Hirabaru
- Department of Surgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Daisuke Kawahara
- Department of Surgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Hirotaka Tokai
- Department of Surgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Kazumasa Noda
- Department of Surgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Keiji Inoue
- Department of Surgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Masashi Haraguchi
- Department of Surgery, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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16
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Zanetto A, Senzolo M, Blasi A. Perioperative management of antithrombotic treatment. Best Pract Res Clin Anaesthesiol 2020; 34:35-50. [PMID: 32334786 DOI: 10.1016/j.bpa.2020.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/13/2019] [Accepted: 01/06/2020] [Indexed: 01/10/2023]
Abstract
End-stage liver disease is characterized by multiple and complex alterations of hemostasis that are associated with an increased risk of both bleeding and thrombosis. Liver transplantation further challenges the feeble hemostatic balance of patients with decompensated cirrhosis, and the management of antithrombotic treatment during and after transplant surgery, which is particularly difficult. Bleeding was traditionally considered the major concern during and early after surgery, but it is increasingly recognized that transplant recipients may also develop thrombotic complications. Pathophysiology of hemostatic complications during and after transplantation is multifactorial and includes pre-, intra-, and postoperative risk factors. Risk stratification is important, as it helps the identification of high-risk recipients in whom antithrombotic prophylaxis should be considered. In recipients who develop thrombosis during or after surgery, prompt treatment is indicated to prevent graft failure, retransplantation, and death.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Annabel Blasi
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain.
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17
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Gürtler K, Giebl A, Spring O. [82 years old, male high-risk cardiac patient to planned Y-prosthesis implantation for abdominal aortic aneurysm : Preparation for the medical specialist examination: part 38]. Anaesthesist 2019; 68:255-260. [PMID: 31673751 DOI: 10.1007/s00101-019-00675-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- K Gürtler
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - A Giebl
- Institut für Transfusionsmedizin und Hämostaseologie, Universitätsklinikum Augsburg, Augsburg, Deutschland
| | - O Spring
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
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18
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Ertugay S, Kudsioğlu T, Şen T. Consensus Report on Patient Blood Management in Cardiac Surgery by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care (SCTAIC). TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2019; 27:429-450. [PMID: 32082905 PMCID: PMC7018143 DOI: 10.5606/tgkdc.dergisi.2019.01902] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 01/18/2023]
Abstract
Anemia, transfusion and bleeding independently increase the risk of complications and mortality in cardiac surgery. The main goals of patient blood management are to treat anemia, prevent bleeding, and optimize the use of blood products during the perioperative period. The benefit of this program has been confirmed in many studies and its utilization is strongly recommended by professional organizations. This consensus report has been prepared by the authors who are the task members appointed by the Turkish Society of Cardiovascular Surgery, Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care to raise the awareness of patient blood management. This report aims to summarize recommendations for all perioperative blood- conserving strategies in cardiac surgery.
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Affiliation(s)
- Serkan Ertugay
- Department of Cardiovascular Surgery, Ege University School of Medicine, İzmir, Turkey
| | - Türkan Kudsioğlu
- Anesthesiology and Reanimation, University of Health Sciences, Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Taner Şen
- Department of Cardiology, University of Health Sciences, Kütahya
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19
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[Perioperative management of trauma surgery patients treated with direct oral anticoagulants]. Unfallchirurg 2019; 122:633-645. [PMID: 31367841 DOI: 10.1007/s00113-019-0693-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As the population gets older the prevalence of atrial fibrillation and venous thromboembolism also increases. Therefore, more patients require anticoagulation and currently direct oral anticoagulants (DOAC), such as dabigatran etexilate, apixaban, rivaroxaban and edoxaban are preferred to vitamin K antagonists (VKA), mainly because of the more favorable risk-benefit profile with respect to bleeding. Older patients in particular frequently present at the accident and emergency department due to falls and an increased risk of fractures. The perioperative management of these patients who are treated with DOACs is a challenge in the clinical routine and needs special consideration. This article discusses these issues in an interdisciplinary approach and develops strategies for the perioperative management of patients treated with DOACs and undergoing trauma or orthopedic surgery.
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20
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Rawal A, Ardeshna D, Minhas S, Cave B, Ibeguogu U, Khouzam R. Current status of oral anticoagulant reversal strategies: a review. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:411. [PMID: 31660310 DOI: 10.21037/atm.2019.07.101] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Utilization of direct oral anticoagulants (DOAC) have steadily increased since their approval and are now recommended over warfarin for both stroke prevention in nonvalvular atrial fibrillation and treatment of venous thromboembolism (VTE). With increased DOAC use, the number of major bleeding events requiring medical intervention will continue to rise. Until 2015, warfarin maintained an advantage as the only oral anticoagulant with a specific reversal agent. Since then, idarucizumab has been approved for dabigatran reversal and recently, andexanet alfa was granted approval for the reversal of apixaban or rivaroxaban in patients with life-threatening or uncontrolled bleeding events. Due to the manufacturing practices required to yield these reversal therapies, they are available at high cost to hospital systems and as a result, have been met with resistance. Data exists describing both prothrombin complex concentrates (PCC) and andexanet alfa for DOAC reversal, however, without head-to-head comparison. Until future studies are available, current literature must be critically evaluated to aid in the clinical decision-making process of how to treat patients with life-threatening DOAC-related bleeding.
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Affiliation(s)
- Aranyak Rawal
- Department of Internal Medicine-Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Devarshi Ardeshna
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sheharyar Minhas
- Department of Medicine, Nazareth Hospital, Conshohocken, PA, USA
| | - Brandon Cave
- Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA
| | - Uzoma Ibeguogu
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rami Khouzam
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USA
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21
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Ząbczyk M, Kopytek M, Natorska J, Undas A. The effect of DOAC-Stop on lupus anticoagulant testing in plasma samples of venous thromboembolism patients receiving direct oral anticoagulants. ACTA ACUST UNITED AC 2019; 57:1374-1381. [DOI: 10.1515/cclm-2018-1197] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/07/2019] [Indexed: 01/01/2023]
Abstract
Abstract
Background
Direct oral anticoagulants (DOACs) cause false positive lupus anticoagulant (LA) results. We assessed the impact of DOAC-Stop, reversing in vitro effects of DOACs, on LA testing in anticoagulated patients.
Methods
We assessed 75 venous thromboembolism patients aged 44.5±14.6 years. Blood samples were collected 2–28 h since intake of DOACs, including 50 patients on rivaroxaban, 20 on dabigatran and five on apixaban. LA testing was performed at baseline and after DOAC-Stop treatment. Positive LA was defined as the normalized (patient/standard plasma clotting time) LA screening and screening (LA1)/confirmation (LA2) ratios exceeding 1.2.
Results
LA diluted Russell’s viper venom time (dRVVT) normalized screening test revealed abnormal results in 73 (97.3%) and activated partial thromboplastin time (APTT)-LA in 49 (65.3%) patients. In six (8%) patients, antiphospholipid syndrome (APS) was diagnosed. dRVVT LA1/LA2 was abnormal in 35 (50.7%) patients taking DOACs. The APTT ratio was normal in all studied subjects. DOAC-Stop completely removed dabigatran and reduced by 98% rivaroxaban and by 92.3% apixaban concentrations (all p<0.05). After DOAC-Stop screening dRVVT remained prolonged in 34 (49.3%) patients (p<0.001), while dRVVT LA1/LA2 was abnormal in six (8.7%) subjects, with no association with DOAC concentrations at baseline and after DOAC-Stop. The APTT-LA screening test remained prolonged in five (7.2%) patients, while the APTT LA1/LA2 ratio was normal in those subjects. DOAC-Stop did not influence LA testing in APS patients.
Conclusions
Application of DOAC-Stop effectively reduced plasma DOAC concentrations leading to appropriate dRVVT results in up to 97% of VTE patients.
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22
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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.
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23
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Wagner J, Lock JF, Kastner C, Klein I, Krajinovic K, Löb S, Germer CT, Wiegering A. Perioperative management of anticoagulant therapy. Innov Surg Sci 2019; 4:144-151. [PMID: 33977124 PMCID: PMC8059348 DOI: 10.1515/iss-2019-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/24/2019] [Indexed: 11/15/2022] Open
Abstract
About 10% of patients taking a chronic, oral anticoagulant therapy require an invasive procedure that can be associated with an increased risk for peri-interventional or perioperative bleeding. Depending on the risk for thromboembolism and the risk for bleeding, the physician has to decide whether the anticoagulant therapy should be interrupted or continued. Patient characteristics such as age, renal function and drug interactions must be considered. The perioperative handling of the oral anticoagulant therapy differs according to the periprocedural bleeding risk. Patients requiring a procedure with a minor risk for bleeding do not need to pause their anticoagulant therapy. For procedures with an increased risk for perioperative bleeding, the anticoagulant therapy should be adequately paused. For patients on a coumarin derivative with a high risk for a thromboembolic event, a perioperative bridging therapy with a low molecular weight heparin is recommended. Due to an increased risk for perioperative bleeding in patients on a bridging therapy, it is not recommended in patients with a low risk for thromboembolism. For patients taking a non-vitamin K oral anticoagulant, a bridging therapy is not recommended due to the fast onset and offset of the medication.
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Affiliation(s)
- Johanna Wagner
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Medical Center Julius-Maximilians, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany
| | - Johan F Lock
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany
| | - Carolin Kastner
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany
| | - Ingo Klein
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Katica Krajinovic
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Stefan Löb
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany.,Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany
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24
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Perioperative Management of Direct Oral Anticoagulants in Intracranial Surgery. J Neurosurg Anesthesiol 2019; 32:300-306. [PMID: 31306260 DOI: 10.1097/ana.0000000000000629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of direct oral anticoagulants is increasing rapidly, because of perceived benefits over older agents, such as predictable pharmacokinetics and a reduced risk of bleeding. Elderly patients, who are more likely to be prescribed these drugs, are also presenting for neurosurgical procedures more often. The combination of these factors will result in neurosurgeons and neuroanesthesiologists encountering patients prescribed direct oral anticoagulants on an increasingly frequent basis. This review provides a summary of the current evidence pertaining to the perioperative management of these drugs, in the context of elective and emergency intracranial surgery. It highlights emerging therapies, including specific antidotes, as well as areas where the evidence base is likely to improve in the future.
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25
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Abstract
A growing number of patients in Germany receive a long-term prophylactic anticoagulation with phenprocoumone or one of the novel direct oral anticoagulants (NOAC), such as dabigatran, rivaroxaban or apixaban. The most common indication for an oral anticoagulant therapy is atrial fibrillation (approximately 75%) where the anticoagulant therapy can reduce the risk for an embolic event, particularly stroke by 60%. Operations carried out during such a therapy can result in major bleeding complications. On the other hand, suspending anticoagulant therapy can lead to an increased risk of thromboembolisms. Thus, the preoperative assessment should address the bleeding risk of the planned operation, the individual risk of thromboembolism, as well as other factors, such as patient age and renal function. If the individual assessment shows a substantial risk of perioperative bleeding when anticoagulant treatment is continued and a substantial risk of thromboembolism if the treatment is suspended, then a perioperative bridging, for example with low molecular weight heparin, is necessary. Perioperative bridging also leads to an increased risk of perioperative bleeding. Thus, undifferentiated bridging for all patients with atrial fibrillation with anticoagulant treatment is not recommended. Instead, the indications for a perioperative bridging should be decided according to individual risk profiles.
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Coscarella M, Motte S, Dalati MF, Oliveira-E-Silva T, Entezari K, Roumeguere T. New oral anti-coagulation drugs and prostate biopsy: a call for guidelines. Ther Adv Urol 2018; 10:437-443. [PMID: 30574204 PMCID: PMC6295786 DOI: 10.1177/1756287218811037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 10/11/2018] [Indexed: 01/14/2023] Open
Abstract
Background: Prostate biopsy is a rather frequent procedure, mostly performed in outpatient settings. Bleeding complications following this procedure require precise and delicate management of pre-, peri- and post-procedure anti-coagulation treatments. New oral anti-coagulation drugs (NOACs) are increasingly used. However, the management of such treatments is feared and not yet well known to urologists. A protocol for prostate biopsy management of NOACs seems mandatory. Materials and methods: A review of the literature, using Pubmed and Cochrane databases, together with analysis of several medical associations’ recommendations in urology, anaesthesiology, cardiology, oncology and drug safety agency, was performed. Results: There are no recommendations about NOAC management for prostate biopsy available from scientific societies. There is also a lack of specific urological studies. However, several panels of expert recommendations could be helpful in establishing standardized protocols adapted from surgery to prostate biopsy. With the growing use of NOACs, recommendations have shifted to continue anti-coagulant treatment without bridging NOACs for low bleeding risk procedures such as prostate biopsy, in carefully selected groups of patients. Conclusion: Extensive indications coupled with the ease of use of NOACs contribute significantly to the widespread replacement of traditional vitamin K antagonist. Knowing that heparin bridging leads to more bleeding, and in the pursuit of more autonomy and safety, urologists should be able to propose dedicated anti-coagulant management using NOACs adapted to carefully selected patients before the prostate biopsy procedure. Further studies and guidelines specific to the concept of non-bridging for anti-coagulant-requiring patients are mandatory for this routine procedure.
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Affiliation(s)
- Mathieu Coscarella
- Department of Urology, Erasme Hospital, University Clinics of Brussels, Route de Lennik 808, 1070 Brussels, Belgium Department of Urology, CHU St Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Serge Motte
- Department of Vascular Diseases, University Clinics of Brussels, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Mohamad-Fadi Dalati
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Tania Oliveira-E-Silva
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Kim Entezari
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Roumeguere
- Department of Urology, University Clinics of Brussels, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Ibrahim A, Walsh LG, Algaali M, Satti Z, Kiernan TJ, Yan BP. Insight into the perioperative management of direct oral anticoagulants: concerns and considerations. Expert Opin Pharmacother 2018; 20:465-472. [PMID: 30521411 DOI: 10.1080/14656566.2018.1551879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) have gained momentum in recent years in patients requiring anticoagulation for the prevention and management of venous thromboembolism and thromboembolic events caused by atrial fibrillation. The use of these agents involves potential bleeding complications, particularly during invasive procedures. With increasing use of DOACs, adequate knowledge regarding the perioperative management of patients on DOACs has become indispensable. AREAS COVERED This review covers the indications, mechanism of action, and pharmacokinetics of DOACs and their management in different perioperative settings based on various current guidelines and practices. The role of bridging therapy with heparin and the recently developed reversal agents are also discussed. EXPERT OPINION The perioperative management of DOACs is influenced by drug pharmacokinetics, potential comorbidities of the patient and perioperative thrombotic and bleeding risk. In low bleeding risk and minor procedures, continuing DOACs seems to be safe. Interrupting DOACs in high-risk procedures might be necessary and should be based on the elimination half-life of the drug and renal function of the patient. Further research is needed to better clarify the role of recently developed reversal agents in the perioperative setting and to identify specific laboratory tests to guide the perioperative management of DOACs.
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Affiliation(s)
- Abdalla Ibrahim
- a Cardiology Department , University Hospital Limerick , Limerick , Ireland
| | - Leon G Walsh
- b Department of Surgery , University Hospital Limerick , Limerick , Ireland
| | - Mohamed Algaali
- a Cardiology Department , University Hospital Limerick , Limerick , Ireland
| | - Zahir Satti
- a Cardiology Department , University Hospital Limerick , Limerick , Ireland
| | - Thomas J Kiernan
- c Division of Cardiology, Department of Medicine , University Hospital Limerick, Graduate Entry Medical School (GEMS), University of Limerick , Limerick , Ireland
| | - Bryan P Yan
- d Division of Cardiology, Department of Medicine and Therapeutics , The Chinese University of Hong Kong, Prince of Wales Hospital , Hong Kong , China
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Hoffman M, Goldstein JN, Levy JH. The impact of prothrombin complex concentrates when treating DOAC-associated bleeding: a review. Int J Emerg Med 2018; 11:55. [PMID: 31179943 PMCID: PMC6326120 DOI: 10.1186/s12245-018-0215-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 11/11/2018] [Indexed: 12/18/2022] Open
Abstract
Background Bleeding complications are a risk associated with all anticoagulants. Currently, the treatment options for the management of direct oral anticoagulant (DOAC)-associated bleeding are limited. Prothrombin complex concentrates (PCCs) have been proposed as a potential therapeutic option, and evidence regarding their use is increasing. Review Many studies supporting PCC have used preclinical models and healthy volunteers; however, more recently, observational studies have further improved insight into current DOAC reversal strategies. Multiple clinical practice guidelines now specifically suggest use of PCCs for this indication. Specific reversal agents for Factor Xa inhibitors may become available in the near future, but data on their efficacy are still emerging. Conclusions Ultimately, a multimodal approach may be the optimal strategy to restore haemostasis in patients presenting with DOAC-associated coagulopathy. Electronic supplementary material The online version of this article (10.1186/s12245-018-0215-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maureane Hoffman
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA.
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
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Ferrandis Comes R, Llau Pitarch JV. Perioperative and periprocedural management of antithrombotic therapy: Multidisciplinar consensus document. ACTA ACUST UNITED AC 2018; 65:423-425. [PMID: 30041946 DOI: 10.1016/j.redar.2018.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 11/17/2022]
Affiliation(s)
- R Ferrandis Comes
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, España; Universitat de València, Valencia, España.
| | - J V Llau Pitarch
- Servicio de Anestesiología y Reanimación, Hospital Doctor Peset, Valencia, España; Universitat de València, Valencia, España
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Manejo perioperatorio y periprocedimiento del tratamiento antitrombótico: documento de consenso de SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT y AEU. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2018.01.001] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Vivas D, Roldán I, Ferrandis R, Marín F, Roldán V, Tello-Montoliu A, Ruiz-Nodar JM, Gómez-Doblas JJ, Martín A, Llau JV, Ramos-Gallo MJ, Muñoz R, Arcelus JI, Leyva F, Alberca F, Oliva R, Gómez AM, Montero C, Arikan F, Ley L, Santos-Bueso E, Figuero E, Bujaldón A, Urbano J, Otero R, Hermida JF, Egocheaga I, Llisterri JL, Lobos JM, Serrano A, Madridano O, Ferreiro JL. Perioperative and Periprocedural Management of Antithrombotic Therapy: Consensus Document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEU. ACTA ACUST UNITED AC 2018; 71:553-564. [PMID: 29887180 DOI: 10.1016/j.rec.2018.01.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 01/05/2018] [Indexed: 01/17/2023]
Abstract
During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patient's thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most of the Spanish scientific societies of clinical specialities that may play a role in the patient-health care process during the perioperative or periprocedural period, is to recommend some simple and practical guidelines with a view to homogenizing daily clinical practice.
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Affiliation(s)
- David Vivas
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Unidad de Cardiología, Clínica MD Anderson, Madrid, Spain.
| | - Inmaculada Roldán
- Servicio de Cardiología, Hospital Universitario La Paz, CIBER-CV, Madrid, Spain
| | - Raquel Ferrandis
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Universitat de València, Valencia, Spain
| | - Francisco Marín
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, CIBER-CV, Murcia, Spain
| | - Vanessa Roldán
- Servicio de Hematología, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Antonio Tello-Montoliu
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, CIBER-CV, Murcia, Spain
| | - Juan Miguel Ruiz-Nodar
- Servicio de Cardiología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante ISABIAL, CIBER-CV, Alicante, Spain
| | - Juan José Gómez-Doblas
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Victoria, CIBER-CV, Málaga, Spain
| | - Alfonso Martín
- Servicio de Urgencias, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Juan Vicente Llau
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínic Universitari, València, Universitat de València, Valencia, Spain
| | | | - Rafael Muñoz
- Servicio de Cirugía Cardiaca, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Juan Ignacio Arcelus
- Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Francisco Leyva
- Servicio de Cirugía Plástica, Estética y Reparadora, Hospital Clínico San Carlos, Madrid, Spain
| | - Fernando Alberca
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Raquel Oliva
- Servicio de Ginecología y Obstetricia, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Ana María Gómez
- Servicio de Cirugía Torácica, Hospital Clínico San Carlos, Madrid, Spain
| | - Carmen Montero
- Servicio de Neumología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Fuat Arikan
- Servicio de Neurocirugía, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Luis Ley
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Elena Figuero
- Departamento de Especialidades Clínicas Odontológicas (DECO), Facultad de Odontología, Universidad Complutense de Madrid UCM, Madrid, Spain
| | - Antonio Bujaldón
- Facultad de Odontología, Universidad Complutense de Madrid UCM, Madrid, Spain
| | - José Urbano
- Servicio de Radiología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Rafael Otero
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | - José Luis Llisterri
- Medicina de Familia, Centro de Salud Ingeniero Joaquín Benlloch, Valencia, Spain
| | | | - Ainhoa Serrano
- Servicio de Medicina Intensiva, Hospital Clínico Universitario, Valencia, Spain
| | - Olga Madridano
- Servicio de Medicina Interna, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - José Luis Ferreiro
- Área de Enfermedades del Corazón, Hospital Universitario de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
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Schultz NH, Lundblad R, Holme PA. Activated prothrombin complex concentrate to reverse the factor Xa inhibitor (apixaban) effect before emergency surgery: a case series. J Med Case Rep 2018; 12:138. [PMID: 29764497 PMCID: PMC5954448 DOI: 10.1186/s13256-018-1660-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/20/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The lack of an antidote against factor Xa inhibitors in case of major bleeding or need for urgent surgery is a concern to clinicians. Guidelines on managing major bleeding in patients under anticoagulation with a factor Xa inhibitor suggest several hemostatic agents to reverse the effect, but there is no consensus regarding the choice of drug or appropriate dose. The ability of prothrombin complex concentrate, activated prothrombin complex concentrate, and recombinant factor VIIa to reverse the effect of factor Xa inhibitors has been evaluated in animal studies, in vitro studies, and healthy volunteers, but not yet in randomized clinical studies. CASE PRESENTATION We report a consecutive case series of patients under factor Xa inhibitor (apixaban) treatment who received activated prothrombin complex concentrate to reverse the anticoagulation effect before emergency cardiovascular surgery. Patient 1, a 63-year-old white man, was operated with replacement of the aortic valve; patient 2, a 65-year-old white man, underwent heart transplantation; patient 3, a 68-year-old white man, was operated for acute type A aortic dissection. They all received activated prothrombin complex concentrate 25 IU/kg immediately before surgery. In two of the cases, the global coagulation assay thromboelastometry (ROTEM™) was performed before and after administering activated prothrombin complex concentrate. The ROTEM™ clotting time was reduced from 1900 seconds to 740 seconds and from 1482 to 807 seconds, respectively, after administering a dose of 25 IU/kg activated prothrombin complex concentrate. The apixaban concentration before reversal was within the range considered to be the therapeutic level in all cases. No bleeding complications occurred during surgery, but one case was complicated with bleeding postoperatively. No thromboembolic complications were observed during or after surgery. CONCLUSIONS Activated prothrombin complex concentrate 25 IU/kg reversed the anticoagulation effect of apixaban effectively and safely before emergency cardiovascular surgery.
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Affiliation(s)
- Nina Haagenrud Schultz
- Department of Haematology, Oslo University Hospital, Box 4950, N-0424 Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Box 4950, N-0424 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Box 1171, Blindern, N-0318 Oslo, Norway
- Department of Haematology, Akershus University Hospital, N-1478 Lørenskog, Norway
| | - Runar Lundblad
- Department of Cardiothoracic Surgery, Oslo University Hospital, Box 4950, N-0424 Oslo, Norway
| | - Pål Andre Holme
- Department of Haematology, Oslo University Hospital, Box 4950, N-0424 Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Box 4950, N-0424 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Box 1171, Blindern, N-0318 Oslo, Norway
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Taranu R, Redclift C, Williams P, Diament M, Tate A, Maddox J, Wilson F, Eardley W. Use of Anticoagulants Remains a Significant Threat to Timely Hip Fracture Surgery. Geriatr Orthop Surg Rehabil 2018; 9:2151459318764150. [PMID: 29619276 PMCID: PMC5871052 DOI: 10.1177/2151459318764150] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/22/2018] [Indexed: 12/15/2022] Open
Abstract
Introduction: Hip fracture remains the biggest single source of morbidity and mortality in the elderly trauma population, and any intervention focused on quality improvement and system efficiency is beneficial for both patients and clinicians. Two of the variables contributory to improving care and efficiency are time to theater and length of stay, with the overall goal being to improve care as reflected within the achievement of best practice tariff. One of the biggest barriers to optimizing these variables is preinjury anticoagulation. Method: Building on our previous work with warfarin in this population, we utilized a regional hip fracture collaborative network collecting prospective data through the National Hip Fracture Database with custom fields pertaining to all agents, including novel oral anticoagulants. Results: In all, 1965 hip fracture patients median age 83 years (1639 not anticoagulated) were admitted to the 5 centers over 12 months. Median length of stay was 20.71 days; time to theater 23.09 hours, and the populations (anticoagulated vs control) were evenly matched for injury. Anticoagulated patients were delayed to theater (P ≤ .001), were inpatients for longer (P ≤ .001) and gained less best practice tariff (P ≤ .05). All variables per agent were noted and the impact of each assessed. Conclusions: Despite the widespread use of newer anticoagulants, popular due to unmonitored reversal and administration, patients stay longer in hospital and wait longer for surgery than nonanticoagulated patients of the same age and injury. Contemporary perioperative practices impact negatively on the ability to perform timely surgery on hip fracture patients. We propose a guideline specific to the management of anticoagulation in the hip fracture population to aid the optimum preparation of patients for theater, achievement of timely surgery, and potentially reduce length of stay.
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Affiliation(s)
- Razvan Taranu
- James Cook University Hospital, Middlesbrough, United Kingdom
| | | | - Patrick Williams
- ST5 Trauma and Orthopaedics, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Marina Diament
- ST5 Trauma and Orthopaedics, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Anne Tate
- James Cook University Hospital, Middlesbrough, United Kingdom
| | - Jamie Maddox
- James Cook University Hospital, Middlesbrough, United Kingdom
| | - Faye Wilson
- City Hospitals Sunderland NHS Foundation Trust, Sunderland, United Kingdom
| | - Will Eardley
- James Cook University Hospital, Middlesbrough, United Kingdom
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Maegele M, Grottke O, Schöchl H, Sakowitz OA, Spannagl M, Koscielny J. Direct Oral Anticoagulants in Emergency Trauma Admissions. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:575-82. [PMID: 27658470 DOI: 10.3238/arztebl.2016.0575] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Direct (non-vitamin-K-dependent) oral anticoagulants (DOAC) are given as an alternative to vitamin K antagonists (VKA) to prevent stroke and embolic disease in patients with atrial fibrillation that is not due to pathology of the heart valves. Fatal hemorrhage is rarer when DOACs are given (nonvalvular atrial fibrillation: odds ratio [OR] 0.68; 95% confidence interval [95% CI: 0.48; 0.96], and venous thromboembolism: OR 0.54; [0.22; 1.32]). 48% of emergency trauma patients need an emergency operation or early surgery. Clotting disturbances elevate the mortality of such patients to 43%, compared to 17% in patients without a clotting disturbance. This underscores the impor tance of the proper, targeted treatment of trauma patients who are aking DOAC. METHODS This review is based on articles retrieved by a selective search in PubMed and on a summary of expert opinion and the recommendations of the relevant medical specialty societies. RESULTS Peak DOAC levels are reached 2-4 hours after the drug is taken. In patients with normal renal and hepatic function, no drug accumulation, and no drug interactions, the plasma level of DOAC 24 hours after administration is generally too low to cause any clinically relevant risk of bleeding. The risk of drug accumulation is higher in patients with renal dysfunction (creatinine clearance [CrCl] of 30 mL/min or less). Dabigatran levels can be estimated from the thrombin time, ecarin clotting time, and diluted thrombin time, while levels of factor Xa inhibitors can be estimated by means of calibrated chromogenic anti-factor Xa activity tests. Routine clotting studies do not reliably reflect the anticoagulant activity of DOAC. Surgery should be postponed, if possible, until at least 24-48 hours after the last dose of DOAC. For patients with mild, non-life threatening hemorrhage, it suffices to discontinue DOAC; for patients with severe hemorrhage, there are special treatment algorithms that should be followed. CONCLUSION DOACs in the setting of hemorrhage are a clinical challenge in the traumatological emergency room because of the inadequate validity of the relevant laboratory tests. An emergency antidote is now available only for dabigatran.
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Affiliation(s)
- Marc Maegele
- Department of Trauma and Orthopedic Sugery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Cologne and Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Experimental Hemostaseology, Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Department of Anesthesiology and Intensive Care Medicine, AUVA Emergency Hospital, Salzburg (Austria), Department of Neurosurgery, Ludwigsburg Hospital, Ludwigsburg, Department of Anesthesiology, Ludwig Maximilian University of Munich, Munich, Institute for Transfusion Medicine, Charité University Medicine Berlin, Berlin
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Merloz P. Optimization of perioperative management of proximal femoral fracture in the elderly. Orthop Traumatol Surg Res 2018; 104:S25-S30. [PMID: 29203430 DOI: 10.1016/j.otsr.2017.04.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/07/2017] [Accepted: 04/14/2017] [Indexed: 02/02/2023]
Abstract
Proximal femoral fracture in elderly subjects is a major event that is life-threatening in the medium-to-long term. Advanced age, male gender and number of comorbidities largely account for high mortality and require geriatric expertise. Protein-energy malnutrition and bone demineralization increase mortality. Mortality can, on the other hand, be reduced by acting on two variables accessible to medical intervention: daily activities and nutritional status. Functional and neurocognitive assessment allow the risk of dependency to be evaluated, and global geriatric work-up can prevent sudden breakdown of homeostasis. In the emergency setting, pain is to be alleviated, polymedication and anticoagulation therapy checked, and instability (notably cardiac and pulmonary) and confusion syndrome screened for on geriatric and anesthesiologic opinions. Surgery should be implemented without delay, within 48hours of admission, preferably using multimodal anesthesia. The technique should be geared to allow early weight-bearing and mobilization. The most comprehensive care plan involves team-work between emergency physicians, surgeons, orthopedic specialists, anesthesiologists, geriatricians, pharmacists, rehabilitation specialists and nursing staff, to reduce mortality and readmission and improve functional results. Post-fracture coordination seeks to prevent falls and further fractures and to treat bone demineralization.
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Affiliation(s)
- P Merloz
- Clinique universitaire d'orthopédie-traumatologie, CHU Albert-Michallon, BP 217, 38043 Grenoble cedex 9, France.
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Erwin JP, Iung B. Current recommendations for anticoagulant therapy in patients with valvular heart disease and atrial fibrillation: the ACC/AHA and ESC/EACTS Guidelines in Harmony…but not Lockstep! Heart 2018; 104:968-970. [DOI: 10.1136/heartjnl-2017-312758] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:5-33. [PMID: 29029110 DOI: 10.1093/ejcts/ezx314] [Citation(s) in RCA: 250] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Yassa R, Khalfaoui MY, Hujazi I, Sevenoaks H, Dunkow P. Management of anticoagulation in hip fractures: A pragmatic approach. EFORT Open Rev 2017; 2:394-402. [PMID: 29071124 PMCID: PMC5644423 DOI: 10.1302/2058-5241.2.160083] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Hip fractures are common and increasing with an ageing population. In the United Kingdom, the national guidelines recommend operative intervention within 36 hours of diagnosis. However, long-term anticoagulant treatment is frequently encountered in these patients which can delay surgical intervention. Despite this, there are no set national standards for management of drug-induced coagulopathy pre-operatively in the context of hip fractures. The aim of this study was to evaluate the management protocols available in the current literature for the commonly encountered coagulopathy-inducing agents. We reviewed the current literature, identified the reversal agents used in coagulopathy management and assessed the evidence to determine the optimal timing, doses and routes of administration. Warfarin and other vitamin K antagonists (VKA) can be reversed effectively using vitamin K with a dose in the range of 2 mg to 10 mg intravenously to correct coagulopathy. The role of fresh frozen plasma is not clear from the current evidence while prothrombin complex remains a reliable and safe method for immediate reversal of VKA-induced coagulopathy in hip fracture surgery or failed vitamin K treatment reversal. The literature suggests that surgery should not be delayed in patients on classical antiplatelet medications (aspirin or clopidogrel), but spinal or regional anaesthetic methods should be avoided for the latter. However, evidence regarding the use of more novel antiplatelet medications (e.g. ticagrelor) and direct oral anticoagulants remains a largely unexplored area in the context of hip fracture surgery. We suggest treatment protocols based on best available evidence and guidance from allied specialties. Hip fracture surgery presents a common management dilemma where semi-urgent surgery is required. In this article, we advocate an evidence-based algorithm as a guide for managing these anticoagulated patients.
Cite this article: EFORT Open Rev 2017;2:394–402. DOI: 10.1302/2058-5241.2.160083
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Affiliation(s)
| | | | | | | | - Paul Dunkow
- Blackpool Victoria Teaching Hospitals, Blackpool, UK
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Godier A, Dincq AS, Martin AC, Radu A, Leblanc I, Antona M, Vasse M, Golmard JL, Mullier F, Gouin-Thibault I. Predictors of pre-procedural concentrations of direct oral anticoagulants: a prospective multicentre study. Eur Heart J 2017; 38:2431-2439. [DOI: 10.1093/eurheartj/ehx403] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 06/29/2017] [Indexed: 12/20/2022] Open
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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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Koscielny J, Rosenthal C, von Heymann C. Nicht-Vitamin-K-abhängige orale Antikoagulanzien. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0289-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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43
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Ozawa S, Nelson T. Clinical Application of Prothrombin Complex Concentrate in Blood Management in Patients. Crit Care Nurse 2017; 37:49-56. [PMID: 28365649 DOI: 10.4037/ccn2017333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Management of patients receiving anticoagulants is a major factor in achieving better outcomes. Anticoagulant therapy may need to be discontinued or rapidly reversed before urgent surgery or invasive procedures. In these situations, treatment with concentrated vitamin K, fresh frozen plasma, and/or clotting factors can achieve more rapid anticoagulant reversal than can drug discontinuation alone. Activated prothrombin complex concentrate is used to treat hemophiliac patients with acquired factor VIII inhibitors. Nonactivated prothrombin complex concentrates are used for anticoagulant reversal. The concentrates are effective within minutes of dosing, providing a nearly immediate decrease in the international normalized ratio. The concentrates are lyophilized powders that can be quickly reconstituted, do not require ABO blood typing before use, and contain 25 times the concentration of vitamin K-dependent clotting factors compared with fresh frozen plasma. Studies suggest that the concentrates are associated with better clinical end points than is fresh frozen plasma.
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Affiliation(s)
- Sherri Ozawa
- Sherri Ozawa is the clinical director, Institute for Patient Blood Management and Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, NJ, and the executive director of the Society for the Advancement of Blood Management. .,Tiffany Nelson is the clinical director, patient blood management, and the transfusion safety officer for the Florida Hospital System, Orlando, Florida.
| | - Tiffany Nelson
- Sherri Ozawa is the clinical director, Institute for Patient Blood Management and Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, NJ, and the executive director of the Society for the Advancement of Blood Management.,Tiffany Nelson is the clinical director, patient blood management, and the transfusion safety officer for the Florida Hospital System, Orlando, Florida
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Papadopoulos DV, Kostas-Agnantis I, Gkiatas I, Tsantes AG, Ziara P, Korompilias AV. The role of new oral anticoagulants in orthopaedics: an update of recent evidence. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:573-582. [DOI: 10.1007/s00590-017-1940-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/05/2017] [Indexed: 12/27/2022]
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Direct Oral Anticoagulants: An Overview for the Interventional Radiologist. Cardiovasc Intervent Radiol 2016; 40:321-330. [DOI: 10.1007/s00270-016-1521-0] [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: 09/05/2016] [Accepted: 11/25/2016] [Indexed: 01/22/2023]
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46
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Dosage plasmatique de quatre anticoagulants directs par UHPLC/DAD. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2016. [DOI: 10.1016/j.toxac.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Rodríguez-Reyes H, Arauz-Góngora A, Asensio-Lafuente E, Celaya-Cota MDJ, Cordero-Cabra A, Guevara-Valdivia M, Izaguirre-Avila R, Lara-Vaca S, Mariona-Moreno V, Martínez-Flores E, Nava-Townsend S, Pozas-Garza G, Rodríguez-Diez G. [Multidisciplinary meeting about the use of direct oral anticoagulants in nonvalvular atrial fibrillation]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2016; 87:124-143. [PMID: 27578566 DOI: 10.1016/j.acmx.2016.06.006] [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: 01/22/2016] [Revised: 06/17/2016] [Accepted: 06/21/2016] [Indexed: 11/27/2022] Open
Abstract
Knowing the real impact of atrial fibrillation in the stroke, the Sociedad Mexicana of Electrofisiología y Estimulación Cardiaca (SOMEEC) had the initiative to develop a multidisciplinary meeting of experts the with the purpose to update the available scientific evidence from clinical practice guidelines, meta-analyses, controlled clinical trials, and complementing with the experience and views of a group of experts. To meet this goal, SOMEEC gathered a group of specialists in the area of cardiology, electrophysiology, neurology and hematology that given their experience in certain areas, they share the scientific evidence with the panel of experts to leave open a discussion about the information presented in this article. This document brings together the best scientific evidence available and aims to be a useful tool in the decision to use of new oral anticoagulants in nonvalvular atrial fibrillation and ischemic heart disease, or relating to the management of patients with stroke or renal failure, and even those that will be submitted to elective surgery and invasive procedures. In the same, they handled comparative schemes of follow-up and treatment which simplifies the decision making by the specialists participants.
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Affiliation(s)
| | - Antonio Arauz-Góngora
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | | | | | | | - Milton Guevara-Valdivia
- UMAE Hospital de Especialidades «Dr. Antonio Fraga Mouret», Centro Médico Nacional La Raza, Ciudad de México, México
| | - Raúl Izaguirre-Avila
- Departamento de Hematología, Clínica de anticoagulantes, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - Susano Lara-Vaca
- Servicio de Arritmias, Centro Médico IMSS, León Guanajuato, México
| | | | | | - Santiago Nava-Townsend
- Departamento de Electrocardiología, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - Gerardo Pozas-Garza
- Instituto de Cardiología y Medicina vascular del TEC de Monterrey, Monterrey, México
| | - Gerardo Rodríguez-Diez
- Departamento de Electrofisiología, Centro Médico Nacional 20 de Noviembre, Ciudad de México, México
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Monem M, Iskandarani MK, Gokaraju K. Axillary artery pseudoaneurysm resulting in brachial plexus injury in a patient taking new oral anticoagulants. BMJ Case Rep 2016; 2016:bcr-2016-216976. [PMID: 27535738 DOI: 10.1136/bcr-2016-216976] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We discuss the case of an independent 80-year-old Caucasian woman, being treated with new oral anticoagulants for a previous deep vein thrombosis, who had fallen on her right shoulder. She made a delayed presentation to the emergency department with a wrist drop in her right dominant hand. She had right arm bruising with good distal pulses but had a global neurological deficit in the hand. Plain radiographs of the shoulder, humerus, elbow, forearm and wrist demonstrated no fractures. MRI showed a significant right axillary lesion distorting the surrounding soft tissues, including the brachial plexus, and CT with contrast confirmed this to be a large axillary pseudoaneurysm. This was treated with an endovascular stent resulting in slightly improved motor function, but the significant residual deficit required subsequent rehabilitation to improve right upper limb function.
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Affiliation(s)
- Mohammed Monem
- Trauma & Orthopaedic Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | | | - Kishan Gokaraju
- Trauma & Orthopaedic Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
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Crapelli GB, Bianchi P, Isgrò G, Biondi A, de Vincentiis C, Ranucci M. A Case of Fatal Bleeding Following Emergency Surgery on an Ascending Aorta Intramural Hematoma in a Patient Taking Dabigatran. J Cardiothorac Vasc Anesth 2016; 30:1027-31. [DOI: 10.1053/j.jvca.2015.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Indexed: 01/16/2023]
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50
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Drouet L, Bal dit Sollier C, Steiner T, Purrucker J. Measuring non-vitamin K antagonist oral anticoagulant levels: When is it appropriate and which methods should be used? Int J Stroke 2016; 11:748-58. [DOI: 10.1177/1747493016659671] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/27/2016] [Indexed: 12/26/2022]
Abstract
Background Although the need for an emergency intervention may merit laboratory measurement of non-vitamin K antagonist oral anticoagulant (NOAC) concentration or anticoagulant activity, NOACs are not supposed to require routine monitoring due to their stable pharmacological profiles compared with warfarin. Aims To examine situations where NOAC measurement may be useful and to provide information about methodologies available to measure NOAC-related anticoagulation activity. Summary of review The routine coagulation tests, including prothrombin time, thrombin time, activated partial thromboplastin time, and international normalized ratio, have variable sensitivities to NOACs. Tests have been developed for use with specific NOACs, e.g. diluted thrombin time or chromogenic factor Xa assays. In emergency situations, such as severe bleeding, stroke, or a requirement for urgent surgery or procedures, there may be a need to assess anticoagulant activity to guide clinical decision making. In cases where neutralization of the anticoagulant effect is warranted, specific reversal agents are likely to become invaluable medical tools. Evidence to date suggests that dosing decisions for NOACs based on clinical features (e.g. age or renal function) can help optimize the benefit–risk balance without assessment of anticoagulant activity in non-emergency routine situations. Conclusions Regular monitoring of NOAC levels does not provide benefits and cannot be recommended at present. In some specific circumstances, e.g. severe bleeding, before urgent surgery, or before thrombolysis, measurement may be beneficial to assess whether a patient is actively anticoagulated. The availability of NOAC-specific reversal agents may change management practices in emergencies.
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Affiliation(s)
- Ludovic Drouet
- Hôpital Lariboisière, Paris, France and Paris VII University, Paris, France
| | | | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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