Vicente Vicente, Martín Alfonso, Lecumberri Ramón, Coll-Vinent Blanca, Suero Coral, González-Porras José Ramón, Marco Pascual, Mateo José, Roldán Vanesa, Soulard Stéphane, Crespo Carlos, Camats Míriam
Servicio de Hematología y de Oncología Médica, Hospital Universitario Morales Meseguer, Murcia, España.
Servicio de Urgencias, Hospital Universitario Severo Ochoa, Madrid, España.
Emergencias. 2017 Feb;29(1):18-26.
To evaluate the level of agreement between hematologists and emergency medicine physicians regarding the best clinical practices for managing bleeding and anticoagulant reversal.
Nationwide Spanish multicenter Delphi method study with a panel of experts on anticoagulation and the management of bleeding. Two survey rounds were carried out between April and September 2015. Consensus was reached when more than 75% of the panelists scored items in the same tertile.
Fifteen hematologists and 17 emergency medicine specialists from 14 Spanish autonomous communities participated. Consensus was reached on the use of both hemodialysis and an activated prothrombin complex concentrate (PCC) to antagonize significant/major bleeding in patients taking dabigatran. Use of an activated PCC was considered sufficient for patients on rivaroxaban or apixaban. The panel did not consider any PCC to be both effective and safe. Tests for activated partial thromboplastin, thrombin, diluted thrombin, and ecarin clotting times were considered useful in patients treated with dabigatran. A specific anti-Xa activity assay was suggested for patients who developed bleeds while treated with rivaroxaban or apixaban. Specific antidotes for direct-acting oral anticoagulants would be useful when severe bleeding occurs according to 97% of the panelists. Such antidotes would substantially change current treatment algorithms.
The points of consensus were generally in line with clinical practice guidelines, but the Delphi process revealed that there are aspects of the clinical management of bleeding that require unified criteria. The need for specific antidotes for direct-acting oral anticoagulants was emphasized.
评估血液科医生和急诊医学医生在出血管理及抗凝逆转最佳临床实践方面的一致程度。
采用全国性西班牙多中心德尔菲法研究，组建了抗凝及出血管理专家小组。2015年4月至9月间进行了两轮调查。当超过75%的小组成员将项目评定在同一三分位数时，即达成共识。
来自西班牙14个自治区的15名血液科医生和17名急诊医学专家参与了研究。就使用血液透析和活化凝血酶原复合物浓缩剂（PCC）来对抗服用达比加群患者的显著/大出血达成了共识。对于服用利伐沙班或阿哌沙班的患者，使用活化PCC被认为就足够了。专家小组认为没有任何一种PCC既有效又安全。活化部分凝血活酶时间、凝血酶时间、稀释凝血酶时间和蛇静脉酶凝结时间检测被认为对接受达比加群治疗的患者有用。对于在接受利伐沙班或阿哌沙班治疗时发生出血的患者，建议进行特定的抗Xa活性检测。97%的小组成员认为，当发生严重出血时，直接口服抗凝剂的特异性解毒剂会很有用。此类解毒剂将极大地改变当前的治疗算法。
达成共识的要点总体上与临床实践指南一致，但德尔菲法过程表明，出血的临床管理存在需要统一标准的方面。强调了对直接口服抗凝剂特异性解毒剂的需求。
