Annick Steib

Surgery and invasive procedures in patients on long-term treatment with direct oral anticoagulants: thrombin or factor-Xa inhibitors. Recommendations of the Working Group on Perioperative Haemostasis and the French Study Group on Thrombosis and Haemostasis.

Direct oral anticoagulants (DOAs)--inhibitors of thrombin or factor-Xa--are expected to replace vitamin K antagonists in most of their indications. Patients receiving long-term treatment with DOAs are likely to be exposed to elective or emergency surgery or invasive procedures. Owing to the present lack of experience in such conditions, we cannot make recommendations, but only propose perioperative management for optimal safety regarding the risk of bleeding and thrombosis. DOAs may increase surgical bleeding, they have no validated antagonists, they cannot be monitored by simple standardized laboratory assays and their pharmacokinetics vary significantly between patients. Although DOAs differ in many respects, the proposals in the perioperative setting need not be specific to each. For procedures with low haemorrhagic risk, a therapeutic window of 48 hours (last administration 24 hours before surgery, restart 24 hours after) is proposed. For procedures with medium or high haemorrhagic risk, we suggest stopping DOAs 5 days before surgery to ensure complete elimination in all patients. Treatment should be resumed only when the risk of bleeding has been controlled. In patients at high thrombotic risk (e.g. those in atrial fibrillation with a history of stroke), bridging with heparin (low molecular-weight heparin, or unfractionated heparin, if the former is contraindicated) is proposed. In an emergency, the procedure should be postponed for as long as possible (minimum 1-2 half-lives) and non-specific antihaemorrhagic agents, such as recombinant human activated factor VIIa or prothrombin complex concentrates should not be given for prophylactic reversal due to their uncertain benefit-risk.

Intraoperative blood losses and transfusion requirements during adult liver transplantation remain difficult to predict.

PurposeTo identify preoperative factors associated with high blood losses during liver transplantation for chronic endstage liver disease.MethodsFour hundred and ten consecutive patients were included in this retrospective study. Blood losses were calculated, based on transfusion requirements. The population was divided into two groups: the upper quartile was defined as the high blood loss (HBL) group and the lower three quartiles as the low blood loss group. Fourteen preoperative variables were collected. Qualitative variables consisted of the type of hepatopathy, Child-Pugh’s classification, sex, the surgical team’s experience, previous abdominal surgery and portal hypertension. Quantitative variables were age, hemoglobin concentration Hb, platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen concentration, fibrin degradation products (FDP) and euglobulin lysis time. Univariate analysis and stepwise multivariate analysis were conducted.ResultsPatients in the HBL group required 12 units of red blood cell or more to maintain a Hb ≥ 100g·L−1. HBL was associated with severe liver disease, previous abdominal surgery, use of a venovenous bypass and little surgical experience in orthotopic liver transplantation (OLT). In the HBL group several hemostatic parameters were more disturbed before surgery. The multivariate analysis disclosed three independent variables associated with HBL: Hb and FDP concentrations and previous upper abdominal surgery. When combined, these resulted in a high specificity (98%) but low sensitivity to predict blood loss.ConclusionDespite our efforts we were unable to identify predictive risk factors of bleeding during OLT even in a homogeneous population. Centres should evaluate their practice individually in an attempt to identify patients at high risk of being transfused.RésuméObjectifDécouvrir les facteurs préopératoires associés à d’importantes pertes sanguines survenant pendant la greffe du foie pour maladie chronique du foie au stade ultime.MéthodeQuatre cent dix patients successifs ont participé à une étude rétrospective. Les pertes sanguines ont été calculées d’après les besoins transfusionnels. Les participants ont été divisés en deux groupes: le quartile supérieur étant le groupe de perte sanguine élevée (PSE) et les trois quartiles inférieurs, le groupe de perte sanguine faible (PSF). Des 14 variables préopératoires rassemblées, les variables qualitatives ont été: le type d’hépatopathie, la classification de Child-Pugh, le sexe, l’expérience de l’équipe chirurgicale, les interventions abdominales antérieures et l’hypertension portale; les variables quantitatives ont été: l’âge, le taux d’hémoglobine (Hb), la numération plaquettaire, le temps de prothrombine, le temps de céphaline activé, la concentration en fibrinogène, les produits de dégradation de la fibrine (PDF) et le temps de lyse des euglobulines. L’analyse univariée et l’analyse multivariée séquentielle ont été réalisées.RésultatsLes patients du groupe PSE ont eu besoin de 12 unités de globules rouges ou plus pour maintenir une [Hb] ≥ 100g·L−1. La PSE a été associée à: une maladie hépatique sévère, une intervention abdominale antérieure, l’utilisation d’une dérivation veino-veineuse et peu d’expérience en greffe du foie orthotopique (GFO). Dans le groupe de PSE, certains paramètres hémostatiques étaient plus instables avant l’opération. L’analyse multivariée a révélé trois variables indépendantes associées à la PSE: les concentrations d’Hb et de PDF et les interventions abdominales hautes antérieures. Les résultats combinés présentent une forte spécificité (98 %) mais une faible sensibilité à prédire les pertes sanguines.ConclusionMalgré nos efforts, nous n’avons pu déterminer les facteurs de risque prédictifs de saignements pendant la greffe de foie orthotopique chez une population homogène. Les hôpitaux doivent évaluer leur pratique individuelle afin de découvrir les patients à risque d’être transfusés.

Venous thromboembolism prevention in surgery and obstetrics: clinical practice guidelines.

Background and objective: To produce up‐to‐date clinical practice guidelines on the prevention of venous thromboembolism in surgery and obstetrics. Methods: A Steering Committee defined the scope of the topic, the questions to be answered, and the assessment criteria. Eight multidisciplinary working groups (total of 70 experts) performed a critical appraisal of the literature in the following disciplines: pharmacology of antithrombotic agents, orthopaedics; general surgery (gastrointestinal (GI) and varicose vein surgery); urology; gynaecology and obstetrics; thoracic, cardiac and vascular surgery; surgery of the head, neck and spine; and surgery of burns patients. The resultant reports and guidelines were submitted for comment and completion of the Appraisal of Guidelines Research & Evaluation questionnaire to a total of 150 peer reviewers, before producing definite guidelines. Results: The report answers the following questions for each type of surgery: (i) What is the venous thromboembolism incidence according to clinical and/or paraclinical criteria in the absence of prophylaxis? (with stratification of venous thromboembolism risk into low, moderate and high categories); (ii) What is the efficacy and safety of the prophylactic measures used? (iii) When should prophylaxis be introduced and how long should it last? (iv) Does ambulatory surgery affect efficacy and safety of prophylaxis? Conclusions: Apart from answering the above questions, the guidelines provide a summary table for each discipline. This table stratifies types of surgery into the three risk categories, specifies the recommended prophylaxis for venous thromboembolism (pharmacological and/or mechanical) and grades each recommendation. In addition, whenever appropriate, the recommended prophylaxis is adjusted to low‐ and high‐risk patients.

Bronchial blocker compared to double-lumen tube for one-lung ventilation during thoracoscopy.

Background: Video‐assisted thoracoscopic surgery (VATS) requires one‐lung ventilation with a properly collapsed lung. This study compared the Broncho‐Cath double‐lumen endotracheal tube with the Wiruthan bronchial blocker to determine the advantages of one device over the other during anaesthesia with one‐lung ventilation for thoracoscopy.

Chirurgies et actes invasifs chez les patients traités au long cours par un anticoagulant oral anti-IIa ou anti-Xa direct: Propositions du Groupe d’intérêt en hémostase périopératoire (GIHP) et du Groupe d’études sur l’hémostase et la thrombose (GEHT)

Direct oral anticoagulants (DOAs), inhibitors of factor IIa or Xa, are expected to replace vitamin K antagonists in most of their indications. It is likely that patients on long-term treatment with DOAs will be exposed to elective or emergency surgery or invasive procedures. Due to the present lack of experience in such conditions, we cannot make recommendations, but only propose perioperative management for optimal safety as regards the risk of bleeding and thrombosis. DOAs may increase surgical bleeding, they have no validated antagonists, they cannot be monitored by simple, standardised laboratory assays, and their pharmacokinetics vary significantly from patient to patient. Although DOAs differ in many respects, the proposals in the perioperative setting need not be specific to each. For procedures with low risk of haemorrhage, a therapeutic window of 48 h (last administration 24h before surgery, restart 24h after) is proposed. For procedures with medium or high haemorrhagic risk, we suggest stopping DOAs 5 days before surgery to ensure complete elimination of the drug in all patients. The treatment should be resumed only when the risk of bleeding has been controlled. In patients with a high risk of thrombosis (e.g. those in atrial fibrillation with an antecedent of stroke), bridging with heparin (low molecular weight, or unfractionated if the former is contraindicated) is proposed. In emergency, the procedure should be postponed for as long as possible (minimum 1-2 half-lives) and non-specific anti-haemorrhagic agents, such as recombinant human activated factor VIIa, or prothrombin concentrates, should not be given for prophylactic reversal, due to their uncertain benefit-risk.

Lung Function After Lobectomy: A Randomized, Double-Blinded Trial Comparing Thoracic Epidural Ropivacaine/Sufentanil and Intravenous Morphine for Patient-Controlled Analgesia

BACKGROUND: Although thoracic epidural analgesia (TEA) is considered superior to IV opioids for postoperative analgesia after thoracic surgery, a few studies clearly demonstrate an improvement in pulmonary function attributable to TEA using a local anesthetic in combination with an opioid. METHODS: In this prospective, randomized, double-blind study, we compared the effects of TEA with ropivacaine and sufentanil (TEA group) to IV morphine (IV group), as they affected pain and pulmonary function after lobectomy in 68 patients. Pain intensity, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, forced expiratory flows, and sniff nasal inspiratory pressure as a marker of inspiratory muscle strength were measured from the first to the fourth postoperative day. RESULTS: Pain relief was better in the TEA group at rest and on coughing (P < 0.001). The impairment of FVC and FEV1 was less in the TEA group when compared with that in the IV group (P < 0.001 and P = 0.003, respectively). Sniff nasal inspiratory pressure, FEV1/FVC ratio, and expiratory flow values decreased similarly in both groups. In-hospital mortality, as well as postoperative pulmonary complications, was not different between groups. CONCLUSION: After lobectomy, TEA enables a significant increase in pulmonary function concomitant with better pain relief than systemic morphine, although a modest intercostal motor block may occur.

Perioperative management of patients receiving vitamin K antagonists

PurposeAs the number of patients taking vitamin K antagonists (VKA) is growing, the clinician is increasingly faced with having to make decisions regarding anticoagulation therapy before, during and immediately after surgery. In this article we review the indications for VKA and assess their use in the perioperative period based on available pharmacological and clinical data.SourceAn on-line computerized search of Medline was conducted limited to English and French language articles. The bibliographies of relevant articles and additional material from other published sources were retrieved and reviewed.Principal findingsAssessment of patients taking VKA who need surgery must include three factors: 1) the indication for anticoagulation, which determines the thromboembolic risk; 2) the pharmacokinetics of VKA, which determine the moment at which treatment should be discontinued; and 3) the type of surgery, which determines the hemorrhagic risk. Some patients will need to stop VKA treatment and start a substitution or “bridging” anticoagulant therapy, such as unfractionated heparin or low molecular weight heparin, prior to and after surgery. In patients requiring emergency surgery, prothrombin complex concentrate can be used to improve coagulation and is preferable to, although more expensive than fresh frozen plasma.ConclusionsFor the perioperative setting, further studies are required to determine the optimal substitution (“bridging”) regimen and the clinical circumstances that necessitate substitution therapy.RésuméObjectifComme le nombre de patients qui prennent des antagonistes de la vitamine K (AVK) augmente, le clinicien a de plus en plus de décisions à prendre sur ľanticoagulothérapie avant, pendant et immédiatement après une opération. Dans le présent article, nous revoyons les indications pour les AVK et évaluons leur usage périopératoire en nous inspirant des données pharmacologiques et cliniques existantes.SourceUne recherche directe informatisée dans Medline a été menée, limitée aux articles parus en anglais et en français. Les bibliographies des articles pertinents et des documents additionnels ďautres sources ont été trouvés et passés en revue.Constatations principalesĽévaluation des patients qui prennent des AVK et qui doivent être opérés doit comprendre trois facteurs: 1) ľindication pour ľanticoagulation qui détermine le risque thromboembolique; 2) la pharmacocinétique des AVK qui détermine le moment où le traitement doit être interrompu et 3) le type de chirurgie qui détermine le risque hémorragique. Certains patients devront arrêter le traitement aux AVK et commencer un traitement anticoagulant de substitution ou de transition, comme ľhéparine non fractionnée ou de bas poids moléculaire, avant et aprèe ľopération. Chez les patients qui doivent être opérés ďurgence, un concentré de complexe prothrombique, plus cher que le plasma frais congelé mais préférable, peut être utilisé pour améliorer la coagulation.ConclusionD’autres études sont nécessaires pour déterminer, dans le cadre périopératoire, les circonstances cliniques qui nécessitent un traitement de substitution et son dosage optimal.Objectif Comme le nombre de patients qui prennent des antagonistes de la vitamine K (AVK) augmente, le clinicien a de plus en plus de decisions a prendre sur ľanticoagulotherapie avant, pendant et immediatement apres une operation. Dans le present article, nous revoyons les indications pour les AVK et evaluons leur usage perioperatoire en nous inspirant des donnees pharmacologiques et cliniques existantes.

Central laboratory and point of care assessment of perioperative hemostasis

PurposeTo review laboratory investigations required for the diagnosis of a constitutional or acquired defect of hemostasis before surgery, or during the perioperative period in context of rapid evolution and possible therapeutic adjustment.MethodsA review of the literature.Principal findingsSystematic preoperative screening is poorly efficient. It should be restricted to patients selected on clinical history and physical examination. Intra- and postoperative investigation is oriented by the clinical circumstances. In most instances, laboratory investigation is organized as hierarchical steps, the first one including a platelet count, a prothrombin time and activated partial thromboplastin time. According to the results of these assays and to the clinical circumstances, further tests specific of primary hemostasis, coagulation or fibrinolysis are performed. Point of care (POC) monitoring has been developed more recently for the investigation of a perioperative bleeding. Several tests examine platelet functions, others measure whole blood activated partial thromboplastin time or prothrombin time and some explore global hemostasis, allowing the detection of excessive fibrinolysis. Point of care testing provides a rapid and valuable answer but, if one accepts the monitoring of unfractionated heparin during extracorporeal circulation, most assays have not been properly validated.ConclusionThe investigation of hemostasis at the central laboratory and POC testing have distinct objectives. The utility of the former for the diagnosis and the adjustment of therapeutics have been well demonstrated. In contrast, the experience with POC testing is relatively recent, and its utility for patient management remains to be demonstrated in proper clinical trials.RésuméObjectifProposer une revue des examens de laboratoire ďhémostase et des tests « au lit du patient » utilisés pour la surveillance et la prise en charge thérapeutique en période périopératoire.MéthodeRevue de la littérature.Principaux résultatsĽexploration de ľhémostase au laboratoire central est orientée vers le diagnostic ďanomalies constitutionnelles ou acquises avant la chirurgie ou en période périopératoire. Elle participe à la surveillance ďanomalies acquises qui peuvent être rapidement évolutives et à ľajustement des thérapeutiques correctrices. Ľexploration systématique par des tests préopératoires est peu efficace et doit être abandonnée. Les patients ayant des antécédents et un examen clinique pouvant faire soupçonner un trouble de ľhémostase doivent seuls être explorés. Dans la plupart des cas, cette exploration est organisée en étapes successives de complexité croissante. La première étape inclut une numération plaquettaire, un temps de Quick (taux de prothrombine) et un temps de céphaline avec activateur. En fonction des résultats de cette première étape et du contexte clinique, des tests plus spécifiques de ľhémostase primaire, de la coagulation ou de la fibrinolyse sont exécutés secondairement. Ľexploration au lit du malade ou au bloc opératoire est particulièrement utile dans les situations de saignement périopératoire. Il existe plusieurs appareils permettant de tester les fonctions des plaquettes, de mesurer le taux de prothrombine et le temps de céphaline avec activateur sur sang total, ou ďenregistrer le déroulement global du processus de coagulation et de fibrinolyse qui lui succède. De tels systèmes ont ľavantage de donner une réponse rapide, écourtée des délais de transport et de centrifugation des échantillons, mais si ľon fait exception de la surveillance de ľanticoagulation au cours des circulations extra-corporelles, ľajustement thérapeutique à ľaide de ces tests est rapporté par un petit nombre ďéquipes et demande à être validé par des essais cliniques plus larges.ConclusionĽexploration de ľhémostase au laboratoire central et au lit du patient ont des objectifs différents. Ľutilité des tests de laboratoire pour le diagnostic et ľajustement thérapeutique est largement démontrée. Ľexpérience des tests au lit du patient et de leur utilisation pour la prise en charge de celui-ci est encore réduite et reste du domaine de ľinvestigation clinique.

Intra-operative paravertebral block for postoperative analgesia in thoracotomy patients: a randomized, double-blind, placebo-controlled study

OBJECTIVE Epidural analgesia is the gold standard for post-thoracotomy pain relief but is contraindicated in certain patients. An alternative is paravertebral block. We investigated whether ropivacaine, administered through a paravertebral catheter placed by the surgeon, reduced postoperative pain. METHODS In a randomized double-blind study, adult patients with a paravertebral catheter placed by the thoracic surgeon after thoracotomy were randomly assigned to receive through this catheter, either a 0.1 mlkg(-1) bolus of 0.5% ropivacaine, followed by a continuous infusion of 0.1 mlkg(-1)h(-1) for 48 h, or saline at the same scheme of administration. Patients also benefited from patient-controlled analgesia with intravenous morphine (bolus 1mg, lockout time 7 min), paracetamol, and nefopam. The primary endpoint was pain intensity on a visual analog scale at rest and on coughing. Secondary endpoints were total morphine consumption and side effects during the first 48 postoperative hours. Surgeons, anesthesiologists, and all the nurses and caring staff involved in this study were blinded. Solutions of saline and ropivacaine were prepared identically by the central pharmacy, without any possible identification of the product. RESULTS Forty-seven patients with contraindications to epidural anesthesia were included. There were no significant differences between the groups receiving ropivacaine and saline in terms of pain severity at rest and on coughing, mean postoperative morphine consumption (45.7 mg for ropivacaine, 43.2mg in controls), and incidence of morphine-related side effects (nausea and vomiting, urinary retention, pruritus, respiratory rate, and sedation). CONCLUSIONS Paravertebral block using a catheter placed by the thoracic surgeon was ineffective on postoperative pain after thoracotomy and did not confirm the analgesic effect that has been observed after percutaneous catheter placement. A direct comparison of these two placement methods is required.

Possible venous argon gas embolism complicating argon gas enhanced coagulation during liver surgery.

We report a case of a major venous argon embolism during argon beam coagulation of a liver biopsy. The essential signs were an abrupt reduction in end‐tidal carbon dioxide partial pressure, in SpO2 and in systolic arterial pressure, at the time of coagulation. Spontaneous recovery was observed within 10 min. Precautions in respect of usage are highlighted.