Eijgenraam P, ten Cate H, ten Cate-Hoek A J
1Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University, Maastricht, the Netherlands.
Neth J Med. 2014 Apr;72(3):157-64.
Perioperative bridging with low-molecularweight heparins (LMWH) is applied to minimise the risk of thromboembolism (TE). Guidelines characterise patients at risk and strategies to be followed. We assessed guideline adherence in bridging episodes and identified possible risk factors for bleeding in a retrospective cohort study.
We searched the electronic patient data system of the Maastricht anticoagulation service, the Netherlands. We identified 181 patients on chronic anticoagulation who underwent surgery (222 procedures) and were bridged with LMWH. Guideline adherence was defined in terms of the relation between TE risk and the dose of LMWH administered, the bleeding risk of the procedure and the duration of postprocedural administration of LMWH. Logistic regression was used to identify risk factors for bleeding.
Of all low TE risk patients (n=102), 84.3% were treated with therapeutic doses of LMWH. The median duration of postprocedural LMWH administration was eight days. The 30-day incidence of major bleeding in the entire group (n=222) was 11.3%. Two patients (0.90%) experienced a deep venous thrombosis. Creatinine clearance ≤40 ml/min (odds ratio (OR) 5.03, 95% confidence interval (CI) 1.25 to 20.26) and dental procedures (OR 3.32, 95% CI 1.22 to 9.04) were independent predictors for total bleeding.
Guideline adherence was low, leading to prolonged bridging procedures, excess treatment of patients and high bleeding rates. The majority of patients had a low thromboembolic risk profile or underwent low-risk procedures. For patients with decreased creatinine clearance, reduced doses of LMWH should be considered to reduce bleeding risk.
围手术期使用低分子量肝素（LMWH）进行桥接治疗，以尽量降低血栓栓塞（TE）风险。指南对有风险的患者及应遵循的策略进行了描述。我们在一项回顾性队列研究中评估了桥接治疗过程中对指南的遵循情况，并确定了出血的可能危险因素。
我们检索了荷兰马斯特里赫特抗凝服务中心的电子患者数据系统。我们确定了181例接受慢性抗凝治疗且接受手术（222例手术）并使用LMWH进行桥接治疗的患者。指南遵循情况根据TE风险与所给予的LMWH剂量之间的关系、手术的出血风险以及术后LMWH给药持续时间来定义。采用逻辑回归分析确定出血的危险因素。
在所有低TE风险患者（n = 102）中，84.3%接受了治疗剂量的LMWH治疗。术后LMWH给药的中位持续时间为8天。整个组（n = 222）的30天大出血发生率为11.3%。2例患者（0.90%）发生深静脉血栓形成。肌酐清除率≤40 ml/min（比值比（OR）5.03，95%置信区间（CI）1.25至20.26）和牙科手术（OR 3.32，95% CI 1.22至9.04）是总出血的独立预测因素。
对指南的遵循情况较低，导致桥接治疗时间延长、患者过度治疗和出血率较高。大多数患者血栓栓塞风险较低或接受低风险手术。对于肌酐清除率降低的患者，应考虑减少LMWH剂量以降低出血风险。
