Surgery and invasive procedures in patients on long-term treatment with oral direct thrombin or factor Xa inhibitors

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 24. h before surgery, restart 24. h 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. © 2011 Elsevier Masson SAS.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Recomendaciones de consenso SEDAR-SEMICYUC sobre el manejo de las alteraciones de la hemostasia en los pacientes graves con infección por COVID-19

[spa] La infección por el coronavirus SARS-CoV-2, causante de la enfermedad denominada COVID-19, provoca alteraciones fundamentalmente en el sistema respiratorio. En los pacientes graves, con frecuencia la enfermedad evoluciona a un síndrome de distrés respiratorio agudo que puede predisponer a los pacientes a un estado de hipercoagulabilidad, con trombosis tanto a nivel venoso como arterial. Esta predisposición presenta una fisiopatología multifactorial, relacionada tanto con la hipoxia como con el grave proceso inflamatorio ligado a esta patología, además de los factores trombóticos adicionales presentes en muchos de los pacientes. Ante la necesidad de optimizar el manejo de la hipercoagulabilidad, los grupos de trabajo de las sociedades científicas de Anestesiología-Reanimación y Terapéutica del Dolor (SEDAR) y de Medicina Intensiva, Crítica y de Unidades Coronarias (SEMICYUC) han desarrollado un consenso para establecer unas pautas de actuación frente a las alteraciones de la hemostasia observadas en los pacientes graves COVID-19. Estas recomendaciones incluyen la profilaxis de la enfermedad tromboembólica venosa en pacientes graves y en el periparto, el manejo de los pacientes en tratamiento crónico con fármacos antiagregantes o anticoagulantes, de las complicaciones hemorrágicas en la evolución de la enfermedad y de la interpretación de las alteraciones generales de la hemostasia. Palabras clave: COVID-19, Infecciones por coronavirus, Heparina de bajo peso molecular, Anticoagulantes, Antitrombóticos, Trombosis, Complicaciones del embaraz

Chirurgies et actes invasifs chez les patients traités au long cours par un anticoagulant oral anti-IIa ou anti-Xa direct. Actualisation 2012

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 48h 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 or recent venous thromboembolic event), 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.SCOPUS: re.jinfo:eu-repo/semantics/publishe

Prioridades de investigación en términos de fluidoterapia perioperatoria y monitorización hemodinámica: encuesta de consenso Delphi del Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasia, Medicina Transfusional y Fluidoterapia (SHTF) de la Sociedad Española de Anestesiología y Reanimación (SEDAR)

Background Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance. Methods Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care. Results 77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus. Conclusions The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.Antecedentes La investigación sobre fluidoterapia y monitorización hemodinámica perioperatorias es difícil y costosa. Los objetivos del presente estudio fueron resumir y priorizar estas cuestiones, en orden de importancia investigadora. Métodos Cuestionario estructurado electrónico Delphi a lo largo de tres rondas entre 30 expertos en fluidoterapia y monitorización hemodinámica identificados a través del Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasis, Medicina Transfusional y Fluidoterapia de la Sociedad española de Anestesiología y Reanimación. Resultados Se identificaron 77 cuestiones, que se clasificaron en orden de priorización. Las cuestiones se categorizaron en temas de cristaloides, coloides, monitorización hemodinámica y otros. Se categorizaron 31 cuestiones como de prioridad investigadora esencial, para determinar si los algoritmos de optimización hemodinámica intraoperatorios basados en el Índice de predicción de hipotensión invasivo o no invasivo frente a otras estrategias de manejo podrían reducir la incidencia de complicaciones postoperatorias, así como si el uso de biomarcadores del estrés renal junto con un protocolo de fluidoterapia dirigido por objetivos podría reducir la estancia hospitalaria y la incidencia de insuficiencia renal aguda en pacientes adultos sometidos a cirugía no cardiaca, lográndose el más alto consenso. Conclusiones El Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasis, Medicina Transfusional y Fluidoterapia de la Sociedad española de Anestesiología y Reanimación utilizará estos resultados para la realización de investigació