Douketis James D, Syed Summer, Li Na, Narouze Samer, Radwi Mansoor, Duncan Joanne, Schulman Sam, Spyropoulos Alex C
Department of Medicine McMaster University Hamilton ON Canada.
Department of Anesthesiology McMaster University Hamilton ON Canada.
Res Pract Thromb Haemost. 2020 Dec 16;5(1):159-167. doi: 10.1002/rth2.12430. eCollection 2021 Jan.
The perioperative management of patients taking a direct oral anticoagulant (DOAC) who require a high-bleed-risk surgery and/or neuraxial anesthesia is uncertain. We surveyed clinician practices relating to DOAC interruption and related perioperative management in patients having high-bleed-risk surgery with neuraxial anesthesia, and assess the suitability of a randomized trial of different perioperative DOAC management strategies.
We surveyed members of the American Society of Regional Anesthesia and Pain Medicine, the Canadian Anesthesia Society and Thrombosis Canada. We developed four clinical scenarios involving DOAC-treated patients who required anticoagulant interruption for elective high-bleed-risk surgery. In three scenarios, patients were to receive neuraxial anesthesia, and in one scenario they were to receive general anesthesia. We also asked about the merit of a randomized trial to compare a 2-day versus longer (3- to 5-day) duration of DOAC interruption.
There were 399 survey respondents of whom 356 (89%) were anesthetists and 43 (11%) were medical specialists. The responses indicate uncertainty about the DOAC interruption interval for high-bleed-risk surgery and/or neuraxial anesthesia; anesthetists favor 3- to 5-day interruption whereas medical specialists favor 2-day interruption. Anesthetists were unwilling to proceed with neuraxial anesthesia in patients with a 2-day DOAC interruption interval, preferring to cancel the surgery or switch to general anesthesia. There is general agreement on the need for a randomized trial in this field to compare a 2-day and a 3- to 5-day DOAC interruption management strategy.
There is variability in practices relating to the perioperative management of DOAC-treated patients who require a high-bleed-risk surgery with neuraxial anesthesia; this variability relates to the duration of DOAC interruption in such patients.
对于服用直接口服抗凝剂（DOAC）且需要进行高出血风险手术和/或接受神经轴索麻醉的患者，围手术期管理尚不确定。我们调查了临床医生对于接受神经轴索麻醉的高出血风险手术患者停用DOAC及相关围手术期管理的做法，并评估了一项关于不同围手术期DOAC管理策略的随机试验的适用性。
我们对美国区域麻醉与疼痛医学学会、加拿大麻醉学会和加拿大血栓形成协会的成员进行了调查。我们设计了四种临床场景，涉及需要为择期高出血风险手术停用抗凝剂的DOAC治疗患者。在三种场景中，患者将接受神经轴索麻醉，在一种场景中他们将接受全身麻醉。我们还询问了比较DOAC中断2天与更长时间（3至5天）的随机试验的价值。
共有399名受访者，其中356名（89%）为麻醉医生，43名（11%）为医学专家。调查结果表明，对于高出血风险手术和/或神经轴索麻醉的DOAC中断间隔存在不确定性；麻醉医生倾向于3至5天的中断，而医学专家倾向于2天的中断。对于DOAC中断间隔为2天的患者，麻醉医生不愿意进行神经轴索麻醉，更倾向于取消手术或改为全身麻醉。对于开展一项随机试验以比较DOAC中断2天和3至5天管理策略的必要性，大家普遍达成共识。
对于需要进行高出血风险手术并接受神经轴索麻醉的DOAC治疗患者，围手术期管理的做法存在差异；这种差异与此类患者的DOAC中断持续时间有关。
