Sauter Thomas C, Eberle Balthasar, Wuillemin Walter A, Thiele Thomas, Angelillo-Scherrer Anne, Exadaktylos Aristomenis K, Erdoes Gabor, Cuker Adam, Nagler Michael
Department of Emergency Medicine, Inselspital, University Hospital Bern, Switzerland.
Department of Anaesthesiology and Pain Therapy, Inselspital, University Hospital Bern, Switzerland.
Swiss Med Wkly. 2018 Mar 14;148:w14598. doi: 10.4414/smw.2018.14598. eCollection 2018.
Antithrombotic treatment puts patients at risk of major bleeding. Fast and adequate response to anticoagulant-associated bleeding may not only stop the bleeding but prevent severe complications. However, practical treatment algorithms to guide physicians in emergency situations are lacking. Important principles that arise from management of bleeding in general are (a) implementation of an in-house algorithm, (b) rapid identification and treatment of the bleeding source, (c) adequate fluid resuscitation, (d) consideration of the application of tranexamic acid and (e) appropriate coagulation testing. We present an algorithm for anticoagulant-associated bleeding and urgent surgery, derived from available data and recommendations, and implemented at our institution. Decisions regarding reversal agents or postponing surgery are based on two questions: the occurrence of a life-threatening bleed or urgent indication for surgery, and the presence of a relevant drug level. Immediate application of reversal agents is suggested if the clinical situation is urgent and laboratory test results are delayed or unavailable. A relevant anticoagulant drug level is required in all other cases. We discuss appropriate laboratory assays for all commonly available anticoagulants, report respective target ranges or expected values, discuss time intervals before surgery, and present critical cut-off values to be used as decision criteria. Specific and unspecific reversal agents for all anticoagulants including the direct oral anticoagulants will be presented. We aim to provide practical guidance for physicians in emergency situations. In addition, we summarise and discuss available experimental and clinical data as well as recommendations provided by scientific societies, authorities and manufacturers.
抗栓治疗会使患者面临大出血风险。对抗凝相关出血做出快速且充分的反应不仅可以止血，还能预防严重并发症。然而，目前缺乏在紧急情况下指导医生的实用治疗方案。一般出血管理中出现的重要原则包括：（a）实施院内方案；（b）快速识别并治疗出血源；（c）充分的液体复苏；（d）考虑应用氨甲环酸；（e）进行适当的凝血检测。我们根据现有数据和建议，提出了一种用于抗凝相关出血和紧急手术的方案，并已在我们机构实施。关于使用逆转剂或推迟手术的决策基于两个问题：是否发生危及生命的出血或手术的紧急指征，以及是否存在相关药物水平。如果临床情况紧急且实验室检测结果延迟或无法获得，建议立即应用逆转剂。在所有其他情况下，都需要有相关的抗凝药物水平。我们讨论了所有常用抗凝剂的适当实验室检测方法，报告了各自的目标范围或预期值，讨论了手术前的时间间隔，并给出了用作决策标准的临界值。还将介绍包括直接口服抗凝剂在内的所有抗凝剂的特异性和非特异性逆转剂。我们旨在为紧急情况下的医生提供实用指导。此外，我们总结并讨论了现有的实验和临床数据以及科学协会、权威机构和制造商提供的建议。
