Raquel Ferrandis

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.

New anticoagulants and regional anesthesia.

Purpose of review The use of pharmacological thromboprophylaxis in the perioperative period may conflict with regional anesthetic techniques in which maintaining hemostatic integrity is essential. Recently, new anticoagulants have been developed with more efficacy and a better safety profile. This article reviews the basis for the actual recommendations and the current status and management of these new drugs. Recent findings Recent studies have outlined that the risk of epidural hematoma after neuraxial anesthesia may be higher than estimated. Therefore, it is imperative to follow the published recommendations. The use of new anticoagulant drugs may take into account the pharmacological profile of each one to safely perform regional anesthesia, mainly the time to reach peak plasma level and half-life. Summary When new anticoagulant drugs are used for thromboprophylaxis in orthopedic surgery, the performance of neuraxial anesthetic techniques should be based on their pharmacology. If a peripheral blockade is chosen, these recommendations should be followed when a block is performed in a noncompressible area.

Antiagregantes y anticoagulantes: manejo del paciente quirúrgico anticoagulado

Resumen Entre los grupos farmacologicos de mayor consumo por los pacientes se encuentran tanto los antiagregantes plaquetarios (aspirina, clopidogrel, ticlopidina) como los anticoagulants (acenocumarol, warfarina, heparina de bajo peso molecular, fondaparinux). El manejo de los mismos en el periodo perioperatorio constituye uno de los aspectos esenciales en el cuidado de los pacientes debido a la necesidad de equilibrar adecuadamente el riesgo de sangrado frente al riesgo trombotico (arterial o venoso) que se incrementa en los pacientes quirurgicos. En la presente revision se destacan tres aspectos esenciales. En primer lugar, respecto a los antiagregantes plaquetarios, es habitual que se recomiende su retirada entre 1 semana y 10 dias antes de la cirugia para minimizar el sangrado perioperatorio. Sin embargo, esta practica ha sido puesta en entredicho porque un paciente sin la necesaria cobertura antiagregante puede tener mayor riesgo de desarrollar complicaciones cardiacas, cerebrales o vasculares perifericas. Por ello, la recomendacion de retirar el farmaco durante un determinado tiempo de forma sistematica debe ser rechazada. Actualmente, se deben valorar de forma individual dichos riesgos para minimizar el tiempo en que el paciente esta sin la debida proteccion antiagregante. En segundo lugar, la tromboprofilaxis es necesaria en la mayoria de pacientes quirurgicos por la elevada prevalencia de la enfermedad tromboembolica venosa. Ello implica el empleo de farmacos anticoagulantes, habiendose cuestionado la practica de la anesthesia regional en estos casos. Sin embargo, con las recomendaciones de seguridad establecidas por las diferentes sociedades cientificas, esta practica se ha demostrado segura. Finalmente, la «terapia puente» de los pacientes anticoagulados con acenocumarol se debe realizar mas de forma individualizada y no sistematicamente sin tener en cuenta los riesgos tromboticos de cada paciente. El perioperatorio es un periodo de alto riesgo trombotico arterial y venoso, y el uso optimo de los antiagregantes plaquetarios y de los anticoagulantes debe ser una prioridad para minimizar dicho riesgo sin incrementar el hemorragico. El consenso multidisciplinario es esencial en esta cuestion

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.

Perioperative Management of Antiplatelet-Drugs in Cardiac Surgery

The management of coronary patients scheduled for a coronary artery bypass grafting (CABG), who are receiving one or more antiplatelet drugs, is plenty of controversies. It has been shown that withdrawal of antiplatelet drugs is associated with an increased risk of a thrombotic event, but surgery under an altered platelet function also means an increased risk of bleeding in the perioperative period. Because of the conflict recommendations, this review article tries to evaluate the outcome of different perioperative antiplatelet protocols in patients with coronary artery disease undergoing CABG.

Anestesia y enfermedad tromboembólica

Currently, pharmacological thromboprophylaxis is frequently required in patients undergoing surgery, due to the high risk of deep venous thrombosis in the perioperative period. The administration of these anticoagulant agents (in Spain, usually low molecular weight heparins or fondaparinux, and in future, probably also the new oral anticoagulants dabigatran and rivaroxaban) may conflict with regional anesthetic techniques, in which maintaining hemostatic integrity is essential. Therefore, safety protocols have been designed that allow thromboprophylaxis to be administered with optimal effectiveness and anesthetic techniques to be performed with maximal safety; these protocols are based on the drug used, as well as on the dose and time of administration. The present chapter reviews the details related to these issues.Hoy en dia es muy frecuente la necesidad de proporcionar tromboprofilaxis farmacologica a los pacientes que se someten a una intervencion quirurgica, por el elevado riesgo de que se desarrolle una trombosis venosa profunda en el perioperatorio. La administracion de estos agentes anticoagulantes (habitualmente en nuestro medio heparinas de bajo peso molecular o fondaparinux, y en un futuro probablemente tambien los nuevos anticoagulantes orales dabigatran y rivaroxaban) puede entrar en conflicto con la realizacion de tecnicas anestesicas regionales, en las que es imprescindible mantener la integridad hemostatica. Por ello, se han desarrollado protocolos de seguridad que permiten la tromboprofilaxis con maxima eficacia y la realizacion de las tecnicas anestesicas con la maxima seguridad; estan basados tanto en el farmaco empleado como en la dosis y el momento en que se administran. Se revisan los detalles correspondientes a esta situacion de la practica diaria.

European guidelines on perioperative venous thromboembolism prophylaxis: Neurosurgery

: Although there are numerous publications addressing venous thromboembolism and its prevention in neurosurgery, there are relatively few high-quality studies to guide decisions regarding thromboprophylaxis. In patients undergoing craniotomy, we recommend that if intermittent pneumatic compression (IPC) is used, it should be applied before the surgical procedure or on admission (Grade 1C). In craniotomy patients at particularly high risk for venous thromboembolism, we suggest considering the initiation of mechanical thromboprophylaxis with IPC preoperatively with addition of low molecular weight heparin (LMWH) postoperatively when the risk of bleeding is presumed to be decreased (Grade 2C). In patients with non-traumatic intracranial haemorrhage, we suggest thromboprophylaxis with IPC (Grade 2C). For patients who have had non-traumatic intracranial haemorrhage, we suggest giving consideration to commencement of LMWH or low-dose unfractionated heparin when the risk of bleeding is presumed to be low (Grade 2C). We suggest continuing thromboprophylaxis until full mobilisation of the patient (Grade 2C). For patients undergoing spinal surgery with no additional risk factors, we suggest no active thromboprophylaxis intervention apart from early mobilisation (Grade 2C). For patients undergoing spinal surgery with additional risk factors, we recommend starting mechanical thromboprophylaxis with IPC (Grade 1C), and we suggest the addition of LMWH postoperatively when the risk of bleeding is presumed to be decreased (Grade 2C).

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.

Management of Antiaggregated and Anticoagulated Patients Scheduled for Orthopedic Surgery

Patients undergoing surgery are more and more frequent under the effects of antiplatelet agents or anticoagulant drugs. This situation is a challenge for the surgical team, and their management is of capital importance to avoid bleeding (the risk of bleeding is increased if the hemostasis is not maintained) and thrombosis (the risk to develop venous or arterial thrombi is increased when the anticlotting drugs are stopped).

Letter by Llau and Ferrandis Regarding Article, “Bridging Evidence-Based Practice and Practice-Based Evidence in Periprocedural Anticoagulation”

To the Editor: Nowadays, the number of patients scheduled for surgery who are being treated with an anticoagulant drug is increasing day by day. In the perioperative period, it is necessary to balance the benefits of the anticoagulation with the risk of bleeding. With this aim, the classical bridging strategy, replacing warfarin or acenocoumarol by a low-molecular-weight heparin (at therapeutic or prophylactic doses depending on the thrombotic risk), although it is controversial, continues to be the practice of choice, as the American College of Chest Physicians stated last year.1 New direct oral anticoagulant (DOAC) agents have been recently introduced for chronic anticoagulation in patients with atrial fibrillation …