Complicaciones de anticoagulantes orales / Oral antiacoagulant complications

Febrero 18, 2016. No. 2240

Complicaciones hemorrágicas de los anticoagulantes orales directos. Bleeding complications from the direct oral anticoagulants. Sholzberg M, Pavenski K, Shehata N, Cserti-Gazdewich C, Lin Y. BMC Hematol. 2015 Dec 24;15:18. doi: 10.1186/s12878-015-0039-z. eCollection 2015. Abstract BACKGROUND: Direct oral anticoagulants (DOACs) are now standard of care for the management of thromboembolic risk. A prevalent issue of concern is how to manage direct oral anticoagulant (DOAC)-associated bleeding for which there is no specific antidote available for clinical use. We conducted a retrospective case series to describe the Toronto, Canada multicenter experience with bleeding from dabigatran or rivaroxaban. METHODS: Retrospective chart review of DOAC bleeding necessitating referral to hematology and/or transfusion medicine services at five large University of Toronto affiliated academic hospitals from January 2011 to December 2013. RESULTS: Twenty-six patients with DOAC bleeding were reviewed; 42 % bleeds intracranial and 50 %, gastrointestinal. All patients had at least one risk factor associated with DOAC bleeding reported in previous studies. Inconsistent bleed management strategies were evident. Median length of hospital stay was 11 days (1-90). Five thromboembolic events occurred after transfusion based-hemostatic therapy and there were six deaths. CONCLUSIONS: Management of DOAC bleeding is variable. Clinical trial data regarding DOAC reversal is needed to facilitate optimization and standardization of bleeding treatment algorithms. KEYWORDS: Anticoagulants; Blood transfusion; Dabigatran; Hemorrhage; Rivaroxaban PDF  Anticoagulantes orales Objetivo-Específicos en el servicio de urgencias. Target-specific Oral Anticoagulants in the Emergency Department. Peacock WF, Levy PD, Gonzalez MG, Than M. J Emerg Med. 2016 Feb;50(2):246-57. doi: 10.1016/j.jemermed.2015.02.052. Epub 2015 Nov 21. Abstract BACKGROUND: Emergency physicians make treatment decisions in patients who present to the emergency department (ED) with acute venous thromboembolism (VTE). They also encounter patients on target-specific oral anticoagulants (TSOACs) who require urgent intervention. New approvals and increasing prescriptions for TSOACs (e.g., apixaban, dabigatran, edoxaban, and rivaroxaban) for the management of several thromboembolic disorders warrant an evaluation of the impact of these agents in the ED setting. OBJECTIVE OF THE REVIEW: This review discusses the use of TSOACs in the ED for the treatment of acute VTE, and highlights strategies for the management of patients on TSOACs who present to the ED with other complications, such as bleeding complications or requiring emergency surgery. DISCUSSION: Apixaban, dabigatran, edoxaban, and rivaroxaban have been approved for the treatment of acute VTE. We discuss the impact of this on ED management of TSOAC-naïve patients and highlight results with TSOACs in high-risk subgroups including the elderly and those with prior VTE or active cancer. This review also discusses management strategies for patients on TSOACs. For emergency physicians, strategies for the management of bleeding, approaches to patient care when emergency surgery is needed, laboratory assays for measuring plasma concentrations of TSOACs, and drug-drug interactions are of special importance. CONCLUSIONS: Familiarity with TSOACs will better position emergency physicians to provide state-of-the art care to their patients with VTE and help them manage potentially complicated circumstances related to the chronic use of these drugs. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Más sobre anticoagulación oral / More on oral anticoagulants

Febrero 17, 2016. No. 2239

Manejo de pacientes que toman los nuevos anticoagulantes orales en odontología: discusión sobre las complicaciones Managing patients taking novel oral anticoagulants (NOAs) in dentistry: a discussion paper on clinical implications. Costantinides F, Rizzo R, Pascazio L, Maglione M. BMC Oral Health. 2016 Jan 28;16(1):5. doi: 10.1186/s12903-016-0170-7. Abstract BACKGROUND: The aim of this paper is to contribute to the discussion on how to approach patients taking new orally administered anticoagulants (NOAs) dabigatran etexilate (a direct thrombin inhibitor), rivaroxaban and apixaban (factor Xa inhibitors), before, during and after dental treatment in light of the more recent knowledges. DISCUSSION: In dentistry and oral surgery, the major concerns in treatment of patients taking direct thrombin inhibitors and factor Xa inhibitors is the risk of haemorrhage and the absence of a specific reversal agent. The degree of renal function, the complexity of the surgical procedure and the patient's risk of bleeding due to other concomitant causes, are the most important factors to consider during surgical dental treatment of patients taking NOAs. For patients requiring simple dental extraction or minor oral surgery procedures, interruption of NOA is not generally necessary, while an higher control of bleeding and discontinuation of the drug (at least 24 h) should be requested before invasive surgical procedures, depending on renal functionality. The clinician has to consider that the number of patients taking NOAs is rapidly increasing. Since available data are not sufficient to establish an evidence-based dental management, the dentist must use caution and attention when treating patients taking dabigatran, rivaroxaban and apixaban. PDF Guía para el manejo práctico de anticoagulantes orales directos en TEP Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. Burnett AE, Mahan CE, Vazquez SR, Oertel LB, Garcia DA, Ansell J. J Thromb Thrombolysis. 2016 Jan;41(1):206-32. doi: 10.1007/s11239-015-1310-7. Abstract Venous thromboembolism (VTE) is a serious medical condition associated with significant morbidity and mortality, and an incidence that is expected to double in the next forty years. The advent of direct oral anticoagulants (DOACs) has catalyzed significant changes in the therapeutic landscape of VTE treatment. As such, it is imperative that clinicians become familiar with and appropriately implement new treatment paradigms. This manuscript, initiated by the Anticoagulation Forum, provides clinical guidance for VTE treatment with the DOACs. When possible, guidance statements are supported by existing published evidence and guidelines. In instances where evidence or guidelines are lacking, guidance statements represent the consensus opinion of all authors of this manuscript and are endorsed by the Board of Directors of the Anticoagulation Forum.The authors of this manuscript first developed a list of pivotal practical questions related to real-world clinical scenarios involving the use of DOACs for VTE treatment. We then performed a PubMed search for topics and key words including, but not limited to, apixaban, antidote, bridging, cancer, care transitions,dabigatran, direct oral anticoagulant, deep vein thrombosis, edoxaban, interactions, measurement, perioperative, pregnancy, pulmonary embolism, reversal, rivaroxaban, switching, \thrombophilia, venous thromboembolism, and warfarin to answer these questions. Non- English publications and publications > 10 years old were excluded. In an effort to provide practical information about the use of DOACs for VTE treatment, answers to each question are provided in the form of guidance statements, with the intent of high utility and applicability for frontline clinicians across a multitude of care settings. KEYWORDS: Antidotes; Bridging anticoagulation; Care transitions; DOACs; Direct thrombin inhibitors; Drug interactions; Factor Xa inhibitors; NOACs PDF   Monitoreo de la anticoagulación con los nuevos agentes Monitoring anticoagulant therapy with new oral agents. Ramos-Esquivel A. World J Methodol. 2015 Dec 26;5(4):212-5. doi: 10.5662/wjm.v5.i4.212. eCollection 2015. Abstract Thromboembolic disease is a major leading cause of mortality and morbidity in industrialized countries. Currently, the management of these patients is challenging due to the availability of new drugs with proven efficacy and security compared to traditional oral vitamin K antagonists. These compounds are characterized by a predictable pharmacokinetic profile for which blood monitoring is not routinely needed. Nevertheless, some data have suggested inter-patient variability in the anticoagulant effect of these drugs, raising concerns about their effectiveness and safety. Although mass-spectrometry is the gold standard to determine drug plasma concentrations, this method is not widely available in every-day practice and some coagulation assays are commonly used to determine the anticoagulant effect of these drugs. The present review aims to summarize the current knowledge regarding the clinical question of how and when to monitor patients with new anticoagulant oral agents. KEYWORDS: Anticoagulant agents; Apixaban; Dabigatran; Drug monitoring; Rivaroxaban PDF

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Paro cardiaco y anestesia / Cardiac arrest and anesthesia

Febrero 4, 2016. No. 2227

Incidencia y factores asociados con paro cardiaco perioperatorio dentro de 24 horas de anestesia para cirugía urgente Incidence of and factors associated with perioperative cardiac arrest within 24 hours of anesthesia for emergency surgery. Siriphuwanun V, Punjasawadwong Y, Lapisatepun W, Charuluxananan S, Uerpairojkit K. Risk Manag Healthc Policy. 2014 Sep 4;7:155-62. doi: 10.2147/RMHP.S67935. eCollection 2014. Abstract PURPOSE: To determine the incidence of and factors associated with perioperative cardiac arrest within 24 hours of receiving anesthesia for emergency surgery. PATIENTS AND METHODS: This retrospective cohort study was approved by the ethical committee of Maharaj Nakorn Chiang Mai Hospital, Thailand. We reviewed the data of 44,339 patients receiving anesthesia for emergency surgery during the period from January 1, 2003 to March 31, 2011. The data included patient characteristics, surgical procedures, American Society of Anesthesiologists (ASA) physical status classification, anesthesia information, location of anesthesia performed, and outcomes. Data of patients who had received topical anesthesia or monitoring anesthesia care were excluded. Factors associated with cardiac arrest were identified by univariate analyses. Multiple regressions for the risk ratio (RR) and 95% confidence intervals (CI) were used to determine the strength of factors associated with cardiac arrest. A forward stepwise algorithm was chosen at a P-value <0.05. RESULTS: The incidence (within 24 hours) of perioperative cardiac arrest in patients receiving anesthesia for emergency surgery was 163 per 10,000. Factors associated with 24-hour perioperative cardiac arrest in emergency surgery were age of 2 years or younger (RR =1.46, CI =1.03-2.08, P=0.036), ASA physical status classification of 3-4 (RR =5.84, CI =4.20-8.12, P<0.001) and 5-6 (RR =33.98, CI =23.09-49.98, P<0.001), the anatomic site of surgery (upper intra-abdominal, RR =2.67, CI =2.14-3.33, P<0.001; intracranial, RR =1.74, CI =1.35-2.25, P<0.001; intrathoracic, RR =2.35, CI =1.70-3.24, P<0.001; cardiac, RR =3.61, CI =2.60-4.99, P<0.001; and major vascular; RR =3.05, CI =2.22-4.18, P<0.001), respiratory or cardiovascular comorbidities (RR =1.95, CI =1.60-2.38, P<0.001 and RR =1.38, CI =1.11-1.72, P=0.004, respectively), and patients in shock prior to receiving anesthesia (RR =2.62, CI =2.07-3.33, P<0.001). CONCLUSION: The perioperative incidence of cardiac arrest within 24 hours of anesthesia for emergency surgery was high and associated with multiple factors such as young age (≤2 years old), cardiovascular and respiratory comorbidities, increasing ASA physical status classification, preoperative shock, and surgery site. Perioperative care providers, including surgeons, anesthesiologists, and nurses, should be prepared to manage promptly this high risk group of surgical patients. KEYWORDS: anesthetic care; emergency surgery; perioperative cardiac arrest; retrospective cohort; risk factors PDF  Paro cardiaco intraoperatoria y relacionado con anestesia y su mortalidad en pacientes viejos. Un estudio de 15 años en un hospital de tercer nivel Intraoperative and anesthesia-related cardiac arrest and its mortality in older patients: a 15-year survey in a tertiary teaching hospital. Nunes JC, Braz JR, Oliveira TS, de Carvalho LR, Castiglia YM, Braz LG. PLoS One. 2014 Aug 12;9(8):e104041. doi: 10.1371/journal.pone.0104041. eCollection 2014. Abstract BACKGROUND: Little information is known about factors that influence perioperative and anesthesia-related cardiac arrest (CA) in older patients. This study evaluated the incidence, causes and outcome of intraoperative and anesthesia-related CA in older patients in a Brazilian teaching hospital between 1996 and 2010. METHODS: During the study, older patients received 18,367 anesthetics. Data collected included patient characteristics, surgical procedures, American Society of Anesthesiologists (ASA) physical status, anesthesia type, medical specialty team and outcome. All CAs were categorized by cause into one of four groups: patient's disease/condition-related, surgery-related, totally anesthesia-related or partially anesthesia-related. RESULTS: All intraoperative CAs and deaths rates are shown per 10,000 anesthetics. There were 100 CAs (54.44; 95% confidence intervals [CI]: 44.68-64.20) and 68 deaths (37.02; 95% CI: 27.56-46.48). The majority of CAs were patient's disease-/condition-related (43.5; 95% CI: 13.44-73.68). There were six anesthesia-related CAs (3.26; 95% CI: 0.65-5.87) - 1 totally and 5 partially anesthesia-related, and three deaths, all partially anesthesia-related (1.63; 95% CI: 0.0-3.47). ASA I-II physical status patients presented no anesthesia-related CA. Anesthesia-related CA, absent in the last five years of the study, was due to medication-/airway-related causes. ASA physical status was the most important predictor of CA (odds ratio: 14.52; 95% CI: 4.48-47.08; P<0.001) followed by emergency surgery (odds ratio: 8.07; 95% CI: 5.14-12.68; P<0.001). CONCLUSIONS: The study identified high incidence of intraoperative CAs with high mortality in older patients. The large majority of CAs were caused by factors not anesthesia-related. Anesthesia-related CA and mortality rates were 3.26 and 1.63 per 10,000 anesthetics, with no anesthesia-related CA in the last five years of the study. Major predictors of intraoperative CAs were poorer ASA physical status and emergency surgery. All anesthesia-related CAs were medication-related or airway-related, which is important for prevention strategies. PDF

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