Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, South Australia, Australia.
Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia.
Hosp Pract (1995). 2023 Aug;51(3):155-162. doi: 10.1080/21548331.2023.2206270. Epub 2023 Apr 24.
There is little evidence to guide the perioperative management of patients on a direct oral anticoagulant (DOAC) in the absence of a last known dose. Quantitative serum titers may be ordered, but there is little evidence supporting this.
This multi-center retrospective cohort study of consecutive surgical in-patients with a DOAC assay, performed over a five-year period, aimed to characterize preoperative DOAC assay orders and their impact on perioperative outcomes.
Patients prescribed regular DOAC (both prophylactic and therapeutic dosing) with a preoperative DOAC assay were included. The DOAC assay titer was evaluated against endpoints. Further, patients with an assay were compared against anticoagulated patients who did not receive a preoperative DOAC assay. The primary endpoint was major bleeding. Secondary endpoints included perioperative hemoglobin change, blood transfusions, idarucizumab or prothrombin complex concentrate administration, postoperative thrombosis, in-hospital mortality and reoperation. Adjusted and unadjusted linear regression models were used for continuous data. Binary logistic models were performed for dichotomous outcomes.
1065 patients were included, 232 had preoperative assays. Assays were ordered most commonly by Spinal (11.9%), Orthopedics (15.4%), and Neurosurgery (19.4%). For every 10 ng/ml increase in titer, the hemoglobin decreases by 0.5066 g/L and the odds of a preoperative reversal increases by 13%. Compared to those without an assay, patients with preoperative DOAC assays had odds 1.44× higher for major bleeding, 2.98× higher for in-hospital mortality and 16.3× higher for receiving anticoagulant reversal.
A preoperative DOAC assay order was associated with worse outcomes despite increased reversal administration. However, the DOAC assay titer can reflect the patient's likelihood of bleeding.
在缺乏最后一次已知剂量的情况下，对于正在服用直接口服抗凝剂（DOAC）的患者，围手术期管理几乎没有证据可循。可能会开定量血清效价检测，但几乎没有证据支持这一点。
本多中心回顾性队列研究连续纳入了 5 年内接受 DOAC 检测的手术住院患者，旨在描述术前 DOAC 检测的开单情况及其对围手术期结局的影响。
纳入了接受常规 DOAC（预防和治疗剂量）治疗且术前进行 DOAC 检测的患者。检测效价与终点进行了评估。此外，将接受检测的患者与未接受术前 DOAC 检测的抗凝患者进行了比较。主要终点是大出血。次要终点包括围手术期血红蛋白变化、输血、依达鲁单抗或凝血酶原复合物浓缩物的使用、术后血栓形成、住院期间死亡率和再次手术。连续数据采用调整和未调整的线性回归模型，二分类结果采用二元逻辑回归模型。
共纳入 1065 例患者，其中 232 例患者术前进行了检测。检测最常由脊柱科（11.9%）、骨科（15.4%）和神经外科（19.4%）开单。效价每增加 10ng/ml，血红蛋白下降 0.5066g/L，术前逆转的可能性增加 13%。与未进行检测的患者相比，术前进行 DOAC 检测的患者发生大出血的风险增加 1.44 倍，住院期间死亡率增加 2.98 倍，接受抗凝逆转的风险增加 16.3 倍。
尽管增加了逆转治疗，但术前 DOAC 检测的开单与较差的结局相关。然而，DOAC 检测效价可以反映患者出血的可能性。
