Abstract
Purpose
As the number of patients taking vitamin K antagonists (VKA) is growing, the clinician is increasingly faced with having to make decisions regarding anticoagulation therapy before, during and immediately after surgery. In this article we review the indications for VKA and assess their use in the perioperative period based on available pharmacological and clinical data.
Source
An on-line computerized search of Medline was conducted limited to English and French language articles. The bibliographies of relevant articles and additional material from other published sources were retrieved and reviewed.
Principal findings
Assessment of patients taking VKA who need surgery must include three factors: 1) the indication for anticoagulation, which determines the thromboembolic risk; 2) the pharmacokinetics of VKA, which determine the moment at which treatment should be discontinued; and 3) the type of surgery, which determines the hemorrhagic risk. Some patients will need to stop VKA treatment and start a substitution or “bridging” anticoagulant therapy, such as unfractionated heparin or low molecular weight heparin, prior to and after surgery. In patients requiring emergency surgery, prothrombin complex concentrate can be used to improve coagulation and is preferable to, although more expensive than fresh frozen plasma.
Conclusions
For the perioperative setting, further studies are required to determine the optimal substitution (“bridging”) regimen and the clinical circumstances that necessitate substitution therapy.
Résumé
Objectif
Comme le nombre de patients qui prennent des antagonistes de la vitamine K (AVK) augmente, le clinicien a de plus en plus de décisions à prendre sur ľanticoagulothérapie avant, pendant et immédiatement après une opération. Dans le présent article, nous revoyons les indications pour les AVK et évaluons leur usage périopératoire en nous inspirant des données pharmacologiques et cliniques existantes.
Source
Une recherche directe informatisée dans Medline a été menée, limitée aux articles parus en anglais et en français. Les bibliographies des articles pertinents et des documents additionnels ďautres sources ont été trouvés et passés en revue.
Constatations principales
Ľévaluation des patients qui prennent des AVK et qui doivent être opérés doit comprendre trois facteurs: 1) ľindication pour ľanticoagulation qui détermine le risque thromboembolique; 2) la pharmacocinétique des AVK qui détermine le moment où le traitement doit être interrompu et 3) le type de chirurgie qui détermine le risque hémorragique. Certains patients devront arrêter le traitement aux AVK et commencer un traitement anticoagulant de substitution ou de transition, comme ľhéparine non fractionnée ou de bas poids moléculaire, avant et aprèe ľopération. Chez les patients qui doivent être opérés ďurgence, un concentré de complexe prothrombique, plus cher que le plasma frais congelé mais préférable, peut être utilisé pour améliorer la coagulation.
Conclusion
D’autres études sont nécessaires pour déterminer, dans le cadre périopératoire, les circonstances cliniques qui nécessitent un traitement de substitution et son dosage optimal.
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Ickx, B.E., Steib, A. Perioperative management of patients receiving vitamin K antagonists. Can J Anesth 53 (Suppl 2), S113–S122 (2006). https://doi.org/10.1007/BF03022258
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DOI: https://doi.org/10.1007/BF03022258