Department of Anesthesiology and Intensive Care, Military Teaching Hospital Sainte Anne, Boulevard Sainte Anne, Toulon 83 000, France.
Br J Anaesth. 2013 Nov;111(5):776-7. doi: 10.1093/bja/aet160. Epub 2013 May 5.
Novel oral anticoagulants (NOAs) which directly inhibit thrombin (dabigatran) or factor Xa (rivaroxaban and apixaban) have recently been developed. We report the first case of perioperative management of a patient treated with dabigatran requiring haemodialysis before emergency surgery. A 62-yr-old woman visited the emergency department for a left bi-malleolar ankle fracture; she had a past medical history of severe ischaemic cardiomyopathy, alcoholic cirrhosis Child B, and moderate chronic renal insufficiency. The patient was treated with dabigatran for a left ventricular aneurysm with thrombus. Cutaneous manifestation of a voluminous haematoma required emergency surgery. Blood tests revealed dabigatran anticoagulant activity of 123 ng ml(-1) (therapeutic values: 85-200 ng ml(-1)), activated partial thromboplastin time of 63 s, and a prothrombin ratio of 68%, indicating that dabigatran disturbed coagulation. We decided to perform emergency haemodialysis before surgery. After 2 h, the anticoagulant activity of dabigatran was 11 ng ml(-1), allowing surgery. Surgery proceeded without any problems and the postoperative period was unremarkable. This case highlights the difficulties for the anaesthesiologist regarding emergency perioperative management of patients treated with NOAs and confirms the efficacy of haemodialysis in cases of dabigatran treatment. NOAs should be prescribed with caution, especially for patients with renal or hepatic disease, at least as long as no antagonist is available. In cases of deferred operative urgency in haemodynamically stable patients treated with dabigatran, haemodialysis should be considered to reverse dabigatran's anticoagulant effects.
新型口服抗凝剂（NOAs）可直接抑制凝血酶（达比加群）或因子 Xa（利伐沙班和阿哌沙班），目前已被广泛应用。我们报告了首例接受达比加群治疗的患者围手术期管理的案例，该患者在急诊手术前需要血液透析。一位 62 岁女性因左双踝骨折到急诊就诊，既往有严重缺血性心肌病、酒精性肝硬化 Child B 和中度慢性肾功能不全病史。该患者因左心室动脉瘤伴血栓形成而接受达比加群治疗。皮肤表现为大量血肿，需要紧急手术。血液检查显示达比加群抗凝活性为 123ng/ml（治疗范围：85-200ng/ml），活化部分凝血活酶时间为 63s，凝血酶原比值为 68%，表明达比加群干扰了凝血功能。我们决定在手术前进行紧急血液透析。2 小时后，达比加群的抗凝活性降至 11ng/ml，允许进行手术。手术顺利进行，术后无异常。该病例强调了麻醉医生在处理接受 NOAs 治疗的患者的紧急围手术期管理方面所面临的困难，并证实了血液透析在达比加群治疗中的有效性。在没有拮抗剂的情况下，NOAs 的应用应谨慎，特别是对于合并肾或肝功能不全的患者。对于达比加群治疗的血流动力学稳定的延迟手术的患者，应考虑血液透析来逆转达比加群的抗凝作用。
