Llau Juan V, Ferrandis Raquel, López Forte Cristina
Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínic Universitari de València, Valencia, España.
Cir Esp. 2009 Jun;85 Suppl 1:7-14. doi: 10.1016/S0009-739X(09)71622-7.
Among the drugs most widely consumed by patients are both antiplatelet agents (aspirin, clopidogrel, ticlopidine) and anticoagulants (acenocoumarol, warfarin, low molecular weight heparin, fondaparinux). The use of these drugs in the perioperative period is an essential concern in patient care due to the need to balance the risk of bleeding against thrombotic risk (arterial or venous), which is increased in surgical patients. The present review highlights three main aspects. Firstly, withdrawal of antiplatelet agents is recommended between 1 week and 10 days before surgery to minimize perioperative bleeding. However, this practice has been questioned because patients without the required antiplatelet coverage may be at greater risk of developing cardiac, cerebral or peripheral vascular complications. Therefore, the recommendation of systematic antiplatelet withdrawal for a specific period should be rejected. Currently, risks should be evaluated on an individual basis to minimize the time during which the patient remains without adequate antiplatelet protection. Secondly, thromboprophylaxis is required in most surgical patients due to the high prevalence of venous thromboembolic disease. This implies the use of anticoagulants and the practice of regional anesthesia has been questioned in these patients. However, with the safety recommendations established by the various scientific societies, this practice has been demonstrated to be safe. Finally, "bridge therapy" in patients anticoagulated with acenocoumarol should be performed on an individual basis rather than systematically without taking into account the thrombotic risks of each patient. The perioperative period involves high arterial and venous thrombotic risk and the optimal use of antiplatelet agents and anticoagulants should be a priority to minimize this risk without increasing hemorrhagic risk. Multidisciplinary consensus is essential on this matter.
患者最常使用的药物包括抗血小板药物（阿司匹林、氯吡格雷、噻氯匹定）和抗凝剂（醋硝香豆素、华法林、低分子量肝素、磺达肝癸钠）。由于需要平衡出血风险与血栓形成风险（动脉或静脉），而手术患者的这种风险会增加，因此在围手术期使用这些药物是患者护理中的一个重要问题。本综述强调了三个主要方面。首先，建议在手术前1周和10天之间停用抗血小板药物，以尽量减少围手术期出血。然而，这种做法受到了质疑，因为没有所需抗血小板覆盖的患者可能有更高的发生心脏、脑或外周血管并发症的风险。因此，应摒弃在特定时期系统性停用抗血小板药物的建议。目前，应根据个体情况评估风险，以尽量缩短患者没有足够抗血小板保护的时间。其次，由于静脉血栓栓塞性疾病的高发病率，大多数手术患者需要进行血栓预防。这意味着要使用抗凝剂，并且在这些患者中区域麻醉的做法也受到了质疑。然而，根据各科学协会制定的安全建议，这种做法已被证明是安全的。最后，接受醋硝香豆素抗凝治疗的患者应根据个体情况而非不考虑每位患者的血栓形成风险而系统性地进行“桥接治疗”。围手术期涉及较高的动脉和静脉血栓形成风险，优化使用抗血小板药物和抗凝剂应成为优先事项，以在不增加出血风险的情况下尽量降低这种风险。在这个问题上多学科达成共识至关重要。
