下肢关节置换术后华法林治疗的术后管理建议。

Recommendations for the post-operative management of an existing Warfarin therapy after lower limb joint arthroplasty.

机构信息

The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, UK; Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, UK.

The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, UK; Betsi Cadwaladr University Health Board, Wrexham, UK.

出版信息

Surgeon. 2019 Aug;17(4):225-232. doi: 10.1016/j.surge.2018.08.005. Epub 2018 Sep 5.

DOI:10.1016/j.surge.2018.08.005

PMID:30195864

Abstract

BACKGROUND

Warfarin administration after lower limb joint replacements is associated with a high bleeding risk, creating the circumstances for periprosthetic joint infections, increased treatment costs and prolonged Length of Stay (L.o.S). We believe that previously warfarinized patients can be treated safely and discharged without delays, if appropriate policies are established and adhered to.

METHODS

This is a retrospective cohort study. We have collected and analyzed data from an audit cycle between 2012 and 2015 on: 1) the post-operative Warfarin reloading protocol, identifying 4 distinct patterns: usual dose, 1.5 times or double the usual dose for 2 days and overloading, 2) timing of reloading: Evening of Surgery vs post-op Day 1, 3) frequency of INR testing: daily vs intermittent, 4) time required to reach a therapeutic INR value ≥2.0, 5) rate of INR variations ≥4.0 and 6) bleeding complications, 7) and the overall L.o.S.

RESULTS

We found a significant difference in the time required to reach an INR ≥2.0 between reloading with the usual dose and all other protocols (p < 0.001) without abolishing adverse sequelae. Daily INR testing reduced bleeding complications and INR variations at a significant (p < 0.001) and non-significant level respectively, while timing of restarting showed no significant effect. We found a correlation between INR variations and bleeding complications (odds ratio: 4.65, C.I: 0.59-30.87). 41% of the cohort was discharged on the day their INR turned therapeutic with an average L.o.S of 6.5 days.

CONCLUSION

We recommend to: 1) restart Warfarin at double (or in exceptional cases 1.5 times) the patient's maintenance dose for the first two doses, 2) starting on the Evening of Surgery, 3) with daily INR monitoring after the second loading dose, 4) using point of care testing devices, 5) and dosing thereafter to be guided by an anticoagulation service or computer assistance.

摘要

背景

下肢关节置换术后使用华法林会增加出血风险，从而增加假体周围关节感染的风险、增加治疗费用并延长住院时间（L.o.S）。我们认为，如果制定并遵守适当的政策，之前接受过华法林治疗的患者可以安全地接受治疗并尽快出院，而不会出现延误。

方法

这是一项回顾性队列研究。我们收集并分析了 2012 年至 2015 年期间的一项审计周期中的数据：1）术后华法林再负荷方案，确定了 4 种不同模式：通常剂量、1.5 倍或 2 天内双倍通常剂量以及超负荷剂量，2）再负荷时间：手术当晚与术后第 1 天，3）INR 检测频率：每日与间歇性，4）达到治疗性 INR 值≥2.0 的所需时间，5）INR 变化率≥4.0 的比率，以及 6）出血并发症，7）以及总体住院时间。

结果

我们发现，与使用通常剂量的方案相比，所有其他方案（p<0.001）在达到 INR≥2.0 的时间上存在显著差异，而没有消除不良后果。每日 INR 检测减少了出血并发症和 INR 变化，差异具有统计学意义（p<0.001）和非统计学意义（p=0.062），而重新开始的时间没有显示出显著的效果。我们发现 INR 变化与出血并发症之间存在相关性（比值比：4.65，置信区间：0.59-30.87）。队列中有 41%的患者在 INR 转为治疗性的当天出院，平均住院时间为 6.5 天。