Stebelski L, Brichant J F, Piérard L, Peters P, Sénard M
Rev Med Liege. 2014 Dec;69(12):671-9.
New oral anticoagulants (NOACs) are a major step forward in the field of anticoagulation. As a consequence, the number of patients treated with NOACs that have to undergo surgery constantly increases. The optimal management of such patients is not clearly determined so far as scientifically established data are lacking. A first proposal is to mimic the perioperative management of patients on vitamin-K antagonists. When the risk of perioperative bleeding is low, NOAC intake is stopped 24 hours before surgery. If the risk of postoperative hemorrhage is moderate or high, NOAC treatment is interrupted 5 days before surgery with a low molecular weight heparin bridging whenever necessary. A second option is based on pharmacokinetic data. When the risk of perioperative bleeding is low, NOAC intake is stopped the day before surgery. If the risk of perioperative bleeding is higher, NOAC intake is suspended for 5 half lives before surgery, 48-72 hours or more. This interruption should be for a longer period in the presence of renal failure. When an unforeseen surgery is needed, the procedure must be delayed as late as possible. In case of emergency, non specific pro-hemostatic agents such as prothrombin complexes or recombinant factor VIIa have not strongly proven useful and must only be used in last ditch effort.
新型口服抗凝药（NOACs）是抗凝领域向前迈出的重要一步。因此，接受NOACs治疗且必须接受手术的患者数量不断增加。由于缺乏科学确定的数据，目前此类患者的最佳管理方案尚未明确确定。第一个建议是模仿维生素K拮抗剂治疗患者的围手术期管理。当围手术期出血风险较低时，在手术前24小时停止服用NOAC。如果术后出血风险为中度或高度，则在手术前5天中断NOAC治疗，并在必要时采用低分子量肝素桥接治疗。第二种选择基于药代动力学数据。当围手术期出血风险较低时，在手术前一天停止服用NOAC。如果围手术期出血风险较高，则在手术前暂停服用NOAC 5个半衰期，即48 - 72小时或更长时间。在存在肾功能衰竭的情况下，这种中断时间应更长。当需要进行意外手术时，手术必须尽可能推迟。在紧急情况下，凝血酶原复合物或重组因子VIIa等非特异性促止血剂尚未被充分证明有效，且仅应在万不得已时使用。
