Levy Jerrold H, Connors Jean M, Steiner Marie E, Douketis James, Spyropoulos Alex C
Division of Cardiothoracic Anesthesiology and Critical Care Department of Anesthesiology Duke University School of Medicine Durham North Carolina.
Hematology Division Department of Medicine Brigham and Women's Hospital Harvard Medical School Boston Massachusetts.
Res Pract Thromb Haemost. 2020 Mar 2;4(4):562-568. doi: 10.1002/rth2.12320. eCollection 2020 May.
There is limited information on real-world practice versus current clinical practice guidelines for oral anticoagulant reversal before emergency surgery.
To identify current practice/knowledge gaps for oral anticoagulant reversal emergency surgery among anesthesiologists.
A 22-question survey covering aspects of clinical practice relating to oral anticoagulant reversal was sent to American Society of Anesthesiology members with weekly reminders during data collection from October to December 2018.
Responses were received from 2315 anesthesiologists of which 86% of respondents were United States based. Emergency surgery was defined as occurring within 4 hours of the decision to operate by 60% of respondents. Fresh frozen plasma (FFP) was used by 75% of respondents for vitamin K antagonist (VKA) reversal and by 54% for direct oral anticoagulant (DOAC) reversal in emergency surgery and 67% in major operative bleeding. Only 32% of institutions had emergency anticoagulant reversal protocols, and 54% of respondents selected an international normalized ration (INR) ratio goal for VKA reversal of ≤1.5. Only 13% initially consulted or coordinated management with hematologists, and the final decision regarding coagulation management was made by the respondent in 26% of cases. A coordinated approach with hematologists and cardiologists was reported by 64%, and over half (51%) required approval for prothrombin complex concentrate administration for emergency procedures.
Despite recommendations to the contrary, FFP is extensively used for emergency VKA and DOAC reversal. There is a clear need for institutions to develop guideline-informed recommendations/management algorithms based on input from medical professionals routinely involved in management of these patients.
关于急诊手术前口服抗凝剂逆转的实际临床实践与当前临床实践指南的相关信息有限。
确定麻醉医生在口服抗凝剂逆转急诊手术方面当前的实践/知识差距。
向美国麻醉医师协会成员发送了一份涵盖与口服抗凝剂逆转相关临床实践方面的22个问题的调查问卷，并在2018年10月至12月数据收集期间每周提醒。
收到了2315名麻醉医生的回复，其中86%的受访者来自美国。60%的受访者将急诊手术定义为在决定手术的4小时内进行。在急诊手术中，75%的受访者使用新鲜冰冻血浆（FFP）来逆转维生素K拮抗剂（VKA），54%用于逆转直接口服抗凝剂（DOAC）；在严重手术出血中，这一比例为67%。只有32%的机构有急诊抗凝剂逆转方案，54%的受访者选择VKA逆转的国际标准化比值（INR）目标≤1.5。只有13%的人最初咨询血液科医生或与其协调管理，26%的病例中关于凝血管理的最终决定由受访者做出。64%的人报告了与血液科医生和心脏病专家的协调方法，超过一半（51%）的人在急诊程序中使用凝血酶原复合物浓缩物需要获得批准。
尽管有相反的建议，但FFP仍被广泛用于急诊VKA和DOAC逆转。各机构显然需要根据经常参与这些患者管理的医学专业人员的意见，制定基于指南的建议/管理算法。
