A. Gómez-Luque

The perioperative management of new direct oral anticoagulants: a question without answers

New direct oral anticoagulant agents (DOAC) are currently licensed for thromboprophylaxis after hip and knee arthroplasty and for long-term prevention of thromboembolic events in non-valvular atrial fibrillation as well as treatment and secondary prophylaxis of venous thromboembolism. Some other medical indications are emerging. Thus, anaesthesiologists are increasingly likely to encounter patients on these drugs who need elective or emergency surgery. Due to the lack of experience and data, the management of DOAC in the perioperative period is controversial. In this article, we review available information and recommendations regarding the periprocedural management of the currently most clinically developed DOAC, apixaban, dabigatran, and rivaroxaban. We discuss two trends of managing patients on DOAC for elective surgery. The first is stopping the DOAC 1-5 days before surgery (depending on the drug, patient and bleeding risk) without bridging. The second is stopping the DOAC 5 days preoperatively and bridging with low-molecular-weight heparin. The management of patients on DOAC needing emergency surgery is also reviewed. As no data exist for the use of haemostatic products for the reversal of the anticoagulant effect in these cases, rescue treatment recommendations are proposed.

Clonidine decreases intraoperative bleeding in middle ear microsurgery

Background: The antihypertensive drug clonidine is a centrally acting α2 agonist useful as a premedicant because of its sedative, anxiolytic, and analgesic properties. We examined the effect of clonidine given as an oral preanesthetic medication in producing a bloodless surgical field in patients undergoing middle ear microsurgery. We also evaluated whether the administration of clonidine would alter the reflex cardiovascular response to laryngoscopy and endotracheal intubation, anesthetic requirement, postoperative pain intensity and consumption of analgesics, and pre‐ and postoperative sedation and anxiety.

Anticlotting drugs and regional anaesthetic and analgesic techniques: comparative update of the safety recommendations

&NA; The wide use of anticlotting drugs by patients scheduled for surgery is a challenge for the anaesthesiologist when considering a regional anaesthesia technique. This practice seems safe if there is an appropriate management based on safety intervals established according to the pharmacology of the drug and the regional technique. Some anaesthesiology societies have published recommendations for the safe practice of regional anaesthesia with the simultaneous use of anticoagulants (heparin, low molecular weight heparins, oral anticoagulants (OA), fondaparinux and others) and antiplatelet agents (aspirin, clopidogrel, ticlopidine, argatroban and others). One of the most recent guidelines has been published by the Spanish Society of Anaesthesia and Critical Care. This article reviews these recommendations and compares them with others published in the last years. The recommendations are similar, but some interesting differences can be observed and need to be considered. A European consensus in this setting would probably be necessary.

Female rats show an increased sensibility to the forced swim test depressive-like stimulus in the hippocampus and frontal cortex 5-HT1A receptors

Affective disorders are more common in women. The forced swim test acts like a depressive stimulus. Hippocampus and frontal cortex 5-HT1A receptors of female and male Wistar rats subjected to the forced swim test were compared with a sham group. The forced swim test diminishes (P<0.05) the hippocampus 3H-8OH-DPAT bound in the female rats (184+/-16 fmol/mg protein) with respect to the male rats (309+/-41 fmol/mg protein) and to the female sham rats (255+/-20 fmol/mg protein). The forced swim test increases the frontal cortex 5-HT1A receptors in the female rats with respect to the female sham group (40.4+/-5 versus 24.7+/-4 fmol/mg protein, P<0.05). An increased sensibility of the 5-HT1A receptors to depressive-stimulus may be one mechanism underlying the higher prevalence of depression in female.

Prevention of the renarrowing of coronary arteries using drug-eluting stents in the perioperative period: an update

The management of patients scheduled for surgery with a coronary stent, and receiving 1 or more antiplatelet drugs, has many controversies. The premature discontinuation of antiplatelet drugs substantially increases the risk of stent thrombosis (ST), myocardial infarction, and cardiac death, and surgery under an altered platelet function could also lead to an increased risk of bleeding in the perioperative period. Because of the conflict in the recommendations, this article reviews the current antiplatelet protocols after positioning a coronary stent, the evidence of increased risk of ST associated with the withdrawal of antiplatelet drugs and increased bleeding risk associated with its maintenance, the different perioperative antiplatelet protocols when patients are scheduled for surgery or need an urgent operation, and the therapeutic options if excessive bleeding occurs.

S-adenosyl-l-methionine prevents 5-HT1A receptors up-regulation induced by acute imipramine in the frontal cortex of the rat

S-adenosyl-L-methionine (SAM) has shown efficacy in speeding the onset of the antidepressant effect of imipramine in depressed patients. This effect may be related to their interactions at the serotonin(1A) (5-HT(1A)) receptors. Acute imipramine up-regulated the frontal cortex 5-HT(1A) receptors (B(max), 51.5 +/- 8.4 fmol/mg protein) vs. saline (B(max), 27.5 +/- 5.9 fmol/mg protein), and did not show antidepressant effect. Acute SAM and imipramine+SAM did not modify frontal cortex 5-HT(1A) receptors, and showed antidepressant effects (decrease of the immobility response of 26%, P<0.01; and 47%, P<0.001) vs. saline. All the chronic treatments showed antidepressant effects and up-regulated the hippocampus 5-HT(1A) receptors. SAM prevents the 5-HT(1A) receptor up-regulation induced by acute imipramine in the frontal cortex. This mechanism may contribute to imipramines antidepressant effect.

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

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 patients 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.

Recomendaciones de uso de los anticoagulantes orales directos en el período perioperatorio

Because of the characteristics of direct oral anticoagulants (DOA), the lack of an antidote to completely reverse their anticoagulant effects, the absence of standardization in monitoring of their effects, and limited experience of their use, specific recommendations for their management in the perioperative period or in emergencies are required. In elective surgery, in patients with normal renal function and low hemorrhagic/ thrombotic risk, DOA should be withdrawn 2 days before the intervention; when the hemorrhagic/ thrombotic risk is higher, bridge therapy with a low molecular weight hepatin beginning 5 days before the intervention is proposed as an alternative. In emergency surgery, systematic administration of hemostatic drugs as prophylaxis is not recommended. In DOA-related acute hemorrhage, administration of prothrombin complex concentrate, fresh plasma or factor VIIa should be evaluated, and general measures to control bleeding should be implemented.