J. De Andrés

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.

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.

Ultrasound in peribulbar block: efficacy of a single-injection with short needle: 8AP1-8

analgesia (PCA), paracetamol and NSAIDs in both groups. Primarily, we assessed pain scores with the Visual Analogic Scale (VAS) at 2, 4, 6, 12, 24, 48, 72 and 96 hours af ter surgery and total morphine consumption at 96 hours. Time to mobilization, incidence of nausea, vomiting and complications of TAP catheters were also recorded. Data were compared using Chi-Squared, t-test (mean values, p< 0.05 significant) and Fisher’s exact test. Results: Demographics did not dif fer between the two groups (p>0.05). Continuous TAP block group showed, at rest and in motion, significantly lower pain scores at 2, 6, 12, 24 hours af ter surgery and thereaf ter. At rest, VAS scores in the study compared to control group were: 2.17 vs 4.23 (p= 0.03), 1.25 vs 2.31 (p = 0.02), 0.83 vs 2.08 (p=0.02), 0.67 vs 3.38 (p=0.001). In motion: 2.58 vs 5.62 (p=0.002), 2.08 vs 3.85 (p=0.02), 0.83 vs 2.08 (p=0.02) and 1.83 vs 5.08 (p=0.01). Total morphine consumption at 96 hours was significantly lower in the study group (11 vs 21mg, p= 0.001). Moreover, patients in the continuous TAP group walked af ter the first post operative day (84 vs 15%, p < 0.001), whereas af ter the second day in the control group (100 vs 78%, p=0.22). Nausea and vomiting were similar. Catheters were placed easily without any complications or ropivacaine adverse ef fects. Conclusion: Continuous TAP block following PB abdominoplasty increases postoperative analgesia, decreases opioid requirements and facilitates early mobilization. References: Gravante G Obes Surg 2011;21:278-82

Levosimendan election inotrope in cardiac surgery to high risk patiens: 4AP2-5

Background and Goal of Study: Validating use and safety of the levosimendan as initial drug in high risk patients. It improve the inotropism and avoid the increase of the consumption of myocardical oxigen. Materials and Methods: We have studied 10 patients programmed for cardiac surgery with low ejection fraction (EF<40%). Standard monitoring with pulmonary artery catheter. After the anesthesic induction we proceeded to measure the haemodynamics parameters: MAP, HR, CVP, PCWP, SVR, PVR, CI, SV and SvO2, if patient had an CI <2,5 l/min/m2 and PCWP> 15 mmHg. We started treatment with levosimendan: load dose with 12 μg/kg. for 20 minuntes and continue with maintenance dose with 0,1 μg/kg/min. we used low doses of phenylephrine in continuous perfusion to support systemic and coronary perfusion pressure. They were studied for 4 times: T1 basal, T2 pre-ECC, T3 post-ECC and T4 at 24h postsurgery. Results and Discussion: Whole of patients n=10 (6 coronary patient and 4 coronary and valvular patient). They had Euroscore index preoperative with a death probability more than double of usual. CI increased of progressive way and it was maximum at 24 hours (figure 1).