Departments of 1 Neurosurgery and.
Neurology, University of Pennsylvania, Philadelphia, Pennsylvania.
Neurosurg Focus. 2017 Nov;43(5):E9. doi: 10.3171/2017.8.FOCUS17447.
Patients taking antithrombotic agents are very common in neurosurgical practice. The perioperative management of these patients can be extremely challenging especially as newer agents, with poorly defined laboratory monitoring and reversal strategies, become more prevalent. This is especially true with emergent cases in which rapid reversal of anticoagulation is required and the patient's exact medical history is not available. With an aging patient population and the associated increase in diseases such as atrial fibrillation, it is expected that the use of these agents will continue to rise in coming years. Furthermore, thromboembolic complications such as deep venous thrombosis, pulmonary embolism, and myocardial infarction are common complications of major surgery. These trends, in conjunction with a growing understanding of the hemostatic process and its contribution to the pathophysiology of disease, stress the importance of the complete evaluation of a patient's hemostatic profile in guiding management decisions. Viscoelastic hemostatic assays (VHAs), such as thromboelastography and rotational thromboelastometry, are global assessments of coagulation that account for the cellular and plasma components of coagulation. This FDA-approved technology has been available for decades and has been widely used in cardiac surgery and liver transplantation. Although VHAs were cumbersome in the past, advances in software and design have made them more accurate, reliable, and accessible to the neurosurgeon. VHAs have demonstrated utility in guiding intraoperative blood product transfusion, identifying coagulopathy in trauma, and managing postoperative thromboprophylaxis. The first half of this review aims to evaluate and assess VHAs, while the latter half seeks to appraise the evidence supporting their use in neurosurgical populations.
在神经外科实践中，患者经常使用抗血栓药物。这些患者的围手术期管理极具挑战性，尤其是新型药物的出现，这些药物的实验室监测和逆转策略定义不明确，越来越普遍。在紧急情况下，需要快速逆转抗凝，而患者的具体病史又无法获得，这种情况尤其如此。随着患者人群的老龄化以及房颤等相关疾病的增加，预计这些药物的使用在未来几年将继续增加。此外，深静脉血栓形成、肺栓塞和心肌梗死等血栓栓塞并发症是大手术的常见并发症。这些趋势，加上对止血过程及其对疾病病理生理学的贡献的认识不断提高，强调了全面评估患者止血谱在指导管理决策中的重要性。粘弹性止血测定（VHA），如血栓弹力图和旋转血栓弹力测定，是对凝血的全面评估，考虑了凝血的细胞和血浆成分。这种经过 FDA 批准的技术已经存在了几十年，并在心脏手术和肝移植中得到了广泛应用。尽管 VHA 在过去很繁琐，但软件和设计的进步使其更准确、更可靠，也更容易被神经外科医生使用。VHA 已被证明可用于指导术中血液制品输注、识别创伤性凝血病以及管理术后血栓预防。本综述的前半部分旨在评估和评估 VHA，而后半部分则旨在评估支持其在神经外科人群中应用的证据。
