Lum Diane J, Ross Patricia A, Bishop Martin A, Caetano Michelle L, Malpani Rohil, Streiff Michael B
1 The Johns Hopkins Hospital, Baltimore, MD, USA.
2 Stony Brook University Hospital, Stony Brook, NY, USA.
Ann Pharmacother. 2017 Dec;51(12):1077-1083. doi: 10.1177/1060028017719505. Epub 2017 Jul 5.
In North America, 250,000 patients on vitamin K antagonists require surgical procedures each year. Temporary interruption of oral anticoagulation and perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin are recommended by the American College of Chest Physicians 2012 for select patients.
The study objectives are to evaluate adherence and nonadherence to the Johns Hopkins clinic guidelines for perioperative management of anticoagulation and identify bleeding or thromboembolic events during perioperative management of anticoagulation.
This is a retrospective study of patients who required perioperative management of anticoagulation for an invasive procedure from May 2009 to March 2014. Individualized perioperative anticoagulation management plans were prospectively developed for each patient according to the standardized Johns Hopkins perioperative bridging recommendations and documented in the medical record. Adherence to these standardized Johns Hopkins clinic guidelines, the incidence of thromboembolic events, and bleeding and adverse events during perioperative management were retrieved from the medical record.
In 294 perioperative management cases, there was 1 (0.3%) thromboembolism, 3 (1%) major bleeds, and 21 (7%) minor bleeds. One patient experienced facial swelling after starting enoxaparin. There was no difference in thromboembolic (0 vs 1, P = 1.00), major (1 vs 2, P = 1.00), or minor bleeding (14 vs 7, P = 1.00) events in patients managed by providers who were adherent to guidelines when compared with providers who were nonadherent.
Our study shows that using a standardized guideline for perioperative management of anticoagulation to inform but not to dictate clinical practice leads to low rates of both thromboembolism and bleeding.
在北美，每年有25万名服用维生素K拮抗剂的患者需要接受外科手术。美国胸科医师学会2012年建议，对于部分患者，应暂时中断口服抗凝治疗，并在围手术期使用普通肝素或低分子量肝素进行桥接治疗。
本研究旨在评估患者对约翰霍普金斯医院抗凝围手术期管理指南的依从性和不依从性，并确定抗凝围手术期管理期间的出血或血栓栓塞事件。
这是一项回顾性研究，研究对象为2009年5月至2014年3月期间因侵入性手术需要进行抗凝围手术期管理的患者。根据标准化的约翰霍普金斯围手术期桥接建议，为每位患者前瞻性地制定个性化的围手术期抗凝管理计划，并记录在病历中。从病历中检索对这些标准化约翰霍普金斯医院指南的依从性、血栓栓塞事件的发生率以及围手术期管理期间的出血和不良事件。
在294例围手术期管理病例中，发生1例（0.3%）血栓栓塞、3例（1%）大出血和21例（7%）小出血。1例患者在开始使用依诺肝素后出现面部肿胀。与不遵守指南的医疗服务提供者相比，遵守指南的医疗服务提供者管理的患者在血栓栓塞（0例对1例，P = 1.00）、大出血（1例对2例，P = 1.00）或小出血（14例对7例，P = 1.00）事件方面没有差异。
我们的研究表明，使用标准化的抗凝围手术期管理指南为临床实践提供参考而非强制规定，可降低血栓栓塞和出血的发生率。
