Page 2595 - Hematology_ Basic Principles and Practice ( PDFDrive )

2312 Part XIII Consultative Hematology

TABLE Comparison of the Features of the Direct Oral guidelines recommend that prophylaxis be continued for at least
159.4 Anticoagulants 10–14 days after surgery and in those undergoing hip arthroplasty
or surgery for hip fracture, prophylaxis should be continued for
165
Dabigatran Rivaroxaban Apixaban Edoxaban at least 35 days. In general, patients undergoing arthroscopic
Target Thrombin (IIa) Factor Xa Factor Xa Factor Xa surgery with no prior history of VTE do not require pharmacologic
prophylaxis. 165
Active Drug No Yes Yes Yes
Onset Time (h) 0.5–2 2–4 3–4 1–3
Half Life (h) 12–17 5–13 ~12 9–11 SUMMARY
Renal Excretion 80 33 27 50 The management of surgical or trauma patients in the perioperative
(%)
period can be challenging because of the variability of procedures,
Reversal Agent Idarucizumab PCC PCC PCC risks inherent within the patient and/or procedure, and the limita-
5 g IV bolus tions of time and acuity of the situation. A thorough history of
IV, Intravenous; PCC, prothrombin complex concentrate. bleeding or thrombosis events and a comprehensive medication
record, coupled with appropriate use of coagulation studies, hemo-
static agents and/or blood products, and collaboration with surgical
or trauma teams can lead to improved outcomes for patients. Ongoing
for rivaroxaban, apixaban, and edoxaban. 154-156 In the setting of research into the management of these patients will likely aid clinical
urgent surgery, dabigatran can effectively be reversed with a 5 g bolus decision-making into the future.
of idarucizumab. 157-159 Reversal agents for rivaroxaban, apixaban and
edoxaban are not yet available. PCC can be considered in such
patients. 160,161 SUGGESTED READINGS

Achneck HE, Sileshi B, Jamiolkowski RM, et al: A comprehensive review
PERIOPERATIVE THROMBOPROPHYLAXIS of topical hemostatic agents: efficacy and recommendations for use. Ann
Surg 251:217, 2010.
VTE is the most common cause of preventable death in hospitalized Chee YL, Crawford JC, Watson HG, et al: Guidelines on the assessment of
patients. Thromboprophylaxis in medical patients is discussed in bleeding risk prior to surgery or invasive procedures. British Committee
Chapter 142. In surgical patients, the risk of postoperative VTE for Standards in Haematology. Br J Haematol 140:496, 2008.
depends on the type of surgery and patient factors. Patients undergo- Crescenzi G, Landoni G, Biondi-Zoccai G, et al: Desmopressin reduces
ing nonorthopedic surgery have a variable risk of postoperative VTE, transfusion needs after surgery: a meta-analysis of randomized clinical
whereas those undergoing major orthopedic procedures are at high trials. Anesthesiology 109:1063, 2008.
risk. Therefore the two groups are discussed separately. Douketis JD: Pharmacologic properties of the new oral anticoagulants: a
clinician-oriented review with a focus on perioperative management. Curr
Pharm Des 16:3436, 2010.
Nonorthopedic Surgery Douketis JD, Spyropoulos AC, Spencer FA, et al: Perioperative management
of antithrombotic therapy: Antithrombotic Therapy and Prevention of
In patients undergoing nonorthopedic surgery, the risks of VTE Thrombosis, 9th ed: American College of Chest Physicians Evidence-
are grouped into four categories: very low (<0.5%), low (~1.5%), Based Clinical Practice Guidelines. Chest 141:e326S, 2012.
162
moderate (~3%), and high (~6%). In both the very low– and Guyatt GH, Eikelboom JW, Gould MK, et al: Approach to outcome
low-risk groups, guidelines recommend that patients be managed measurement in the prevention of thrombosis in surgical and medical
with early ambulation and mechanical methods of prophylaxis using patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:
intermittent pneumatic compression devices. In the moderate- and American College of Chest Physicians Evidence-Based Clinical Practice
high-risk groups, guidelines recommend pharmacologic thrombopro- Guidelines. Chest 141:e185S, 2012.
162
phylaxis with LMWH. LMWH is preferred over low-dose UFH Horlocker TT, Wedel DJ, Rowlingson JC, et al: Regional anesthesia in the
because its use is associated with a reduced risk of heparin-induced patient receiving antithrombotic or thrombolytic therapy: American
163
thrombocytopenia. Although LMWH is usually given only while Society of Regional Anesthesia and Pain Medicine Evidence-Based Guide-
the patient is hospitalized, extended prophylaxis for at least 4 weeks lines (Third Edition). Reg Anesth Pain Med 35:64, 2010.
is recommended for patients undergoing abdominal or pelvic surgery Kearon C, Hirsh J: Management of anticoagulation before and after elective
for cancer. If the risk of bleeding is deemed to be too high to enable surgery. N Engl J Med 336:1506, 1997.
pharmacologic thromboprophylaxis, such as in patients undergoing Kwok A, Faigel DO: Management of anticoagulation before and after
neurosurgery or spinal surgery, intermittent pneumatic compression gastrointestinal endoscopy. Am J Gastroenterol 104:3085, quiz 3098,
devices should be used until the bleeding risk subsides. 162 2009.
Leissinger CA, Blatt PM, Hoots WK, et al: Role of prothrombin complex
concentrates in reversing warfarin anticoagulation: a review of the litera-
Orthopedic Surgery ture. Am J Hematol 83:137, 2008.
Logan AC, Yank V, Stafford RS: Off-label use of recombinant factor VIIa
Patients undergoing orthopedic surgery are at high risk for post- in U.S. hospitals: analysis of hospital records. Ann Intern Med 154:516,
operative VTE because they are relatively immobile after surgery 2011.
and because manipulation of the lower limb vascular structures may Paikin JS, Eikelboom JW, Cairns JA, et al: New antithrombotic agents–
164
disrupt the vascular endothelium. Therefore patients undergoing insights from clinical trials. Nature reviews. Cardiology 7:498, 2010.
hip or knee arthroplasty or surgery for hip fracture are all categorized Schulman S, Crowther MA: How I treat with anticoagulants in 2012: new
as high risk. Accordingly, postoperative pharmacologic prophylaxis and old anticoagulants, and when and how to switch. Blood 119:3016,
is recommended and the choices in patients undergoing hip or knee 2012.
arthroplasty include the DOACs, LMWH, or dose-adjusted warfarin;
aspirin is also included as an option in preference to no prophy-
laxis. The DOACs have not been extensively evaluated in patients REFERENCES
undergoing surgery for hip fracture, and LMWH is more commonly
165
used in these patients. In patients undergoing knee arthroplasty, For the complete list of references, log on to www.expertconsult.com.