Perioperative management of patients receiving long-term antithrombotic therapy. Russian Federation of anesthesiologists and reanimatologists guidelines

I.B. Zabolotskikh1,2, M.Yu. Kirov3, V.S. Afonchikov4, A.Yu. Bulanov5, E.V. Grigoriev6, A.I. Gritsan7, M.N. Zamyatin8, I.S. Kurapeev9, K.M. Lebedinskii9, V.V. Lomivorotov10, A.Yu. Lubnin11, M. Ovechkin12, V.I. Potievskaya13, E.V. Roitman14, S.V. Sinkov1,2, V.V. Subbotin15, E.M. Shulutko16

1 FSBI HPE “Kuban State Medical University” of the Ministry of Healthcare of the Russian Federation, Krasnodar

2 SBIHC “Regional Clinical Hospital № 2» MH KK, Krasnodar

3 FSBEI HE “Northern State Medical University” of the Ministry of Healthcare of the Russian Federation, Arkhangelsk

4 SBI “I.I. Dzhanelidze St. Petersburg Research Institute of Ambulance”, St. Petersburg

5 SBIH of Moscow “City Clinical Hospital № 52 DZM”, Moscow

6 FSBEI HE “Kemerovo State Medical University” of the Ministry of Healthcare of the Russian Federation, Kemerovo

7 FSBEI HE «Krasnoyarsk state medical University named after Professor V.F. Voyno-Yasenetsky» Ministry of Healthcare of Russia, Krasnoyarsk

8 FSBI “National Medical and Surgical Center named after N.I. Pirogov” of the Ministry of Healthcare of the Russian Federation, Moscow

9 FSBEI HE “North-Western State Medical University named after I.I. Mechnikov” Ministry of Health of Russia, St. Petersburg

10 FSBEI “National Medical Research Center named after academician E.N. Meshalkin” Ministry of Healthcare of Russia, Novosibirsk

11 FSAI “N.N. Burdenko National Scientific and Practical Center for Neurosurgery” of the Ministry of Healthcare of the Russian Federation, Moscow

12 FSAEI HE “I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation (Sechenov University)”, Moscow

13 FSBI “National Medical Research Radiology Center” of the Ministry of Healthcare of the Russian Federation, Moscow

14 FSBEI HE “Russian National Research Medical University named after N.I. Pirogov” of the Ministry of Healthcare of the Russian Federation, Moscow

15 SBIH “Moscow Clinical Scientific Center named after A.S.Loginov”, Moscow

16 FSBEI “Russian Medical Academy of Postgraduate Education” Ministry of Healthcare of the Russian Federation, Moscow

For correspondence: Igor B. Zabolotskikh, Dr. Med. Sci., professor, head of Department of Anesthesiology, Intensive Care and Transfusiology, Kuban State Medical University; Krasnodar; e-mail: pobeda_zib@mail.ru

For citation: Zabolotskikh IB, Kirov MYu, Afonchikov VS, Bulanov AYu, Grigoryev EV, Gritsan AI, Zamyatin MN, Kurapeev IS, Lebedinskii KM, Lomivorotov VV, Lubnin AYu, Ovechkin AM, Potievskaya VI, Roitman EV, Sinkov SV, Subbotin VV, Shulutko EM. Perioperative management of patients receiving long-term antithrombotic therapy. Russian Federation of anesthesiologists and reanimatologists guidelines. Alexander Saltanov Intensive Care Herald. 2019;1:7–19.

DOI: 10.21320/1818-474X-2019-1-7-19


The review presents the clinical guidelines of the Federation of Anaesthesiology and Resuscitation specialists of Russia, revised in 2018. The recommendations are based on a review of publications and modern international guidelines of the British Hematology Standards Committee (BSH, 2016), the European Society of Cardiology in partnership with the European Society of Cardiothoracic Surgeons (ESC and EACTS, 2018), the American Society of Regional Anesthesia and Pain (ASRA, 2018), The European Society of Anesthesiologists (ESA, 2010), as well as a consensus document of an interdisciplinary group of experts of the Russian Federation.

Perioperative management of patients receiving long-term antithrombotic (antiplatelet and / or anticoagulant) therapy may be problematic, as they often need to interrupt antithrombotic therapy before surgery. In this, it is necessary to maintain a balance between the effectiveness of antithrombotic therapy and its safety by minimizing the frequency of both hemorrhagic and thrombotic complications. The recommendations presented in the review are aimed at achieving the strategic goal of perioperative antithrombotic therapy — minimizing the risk of bleeding subject to the minimum necessary antithrombotic potential.

Keywords: anticoagulant therapy, antiplatelet therapy, interruption of antithrombotic therapy, emergency reversion, regional anesthesia

Received: 23.02.2019


References

  1. Keeling D., Tait R.C., Watson H. Peri-operative management of anticoagulation and antiplatelet Therapy. British Committee for Standards in Haematology. British Journal of Haematology, 2016; 175: 602–613. DOI: 10.1111/bjh.14344
  2. Valgimigli M., Bueno H., Byrne R.A., et al. ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal, 2018; 39: 213–260. DOI: 10.1093/eurheartj/ehx
  3. Horlocker T., Vandermeuelen E., Kopp S., et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg. Anesth. Pain Med. 2018; 43: 263–309. DOI: 10.1097/AAP.0000000000000763
  4. Gogarten W., Vandermeulen E., Aken H.V., Kozek S., Llau J.V., Samama C.M. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur. J. Anaesthesiol. 2010; 27: 999–1015. DOI: 10.1097/EJA.0b013e32833f6f6f
  5. Ревишвили А.Ш., Шляхто Е.В., Замятин М.Н. и др. Особенности оказания экстренной и неотложной медицинской помощи пациентам, получающим прямые оральные антикоагулянты. Согласительный документ междисциплинарной группы экспертов. Вестник аритмологии. 2018; 92: 59–72. DOI: 10.25760/VA-2018-92-59-72
  6. [Revishvili A.SH., Shlyahto E.V., Zamyatin M.N., et al. Osobennosti okazaniya ehkstrennoj i neotlozhnoj medicinskoj pomoshchi pacientam, poluchayushchim pryamye oral’nye antikoagulyanty. Soglasitel’nyj dokument mezhdisciplinarnoj gruppy ehkspertov. Vestnik aritmologii. 2018; 92: 59–72. DOI: 10.25760/VA-2018-92-59-72. (In Russ)]
  7. Burger W., Chemnitius J.M., Kneissl G.D., Rucker G. Low-close aspirin for secondary cardiovascular prevention — Cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation — Review and meta-analysis. Journal of Internal Medicine. 2005; 257: 399–414. DOI: 10.1111/j.1365-2796.2005.01477.x
  8. Singla S., Sachdeva R, Uretsky B.F. The risk of adverse cardiac and bleeding events following noncardiac surgery relative to antiplatelet therapy in patients with prior percutaneous coronary intervention. Journal of the American College of Cardiology. 2012; 60: 2005–2016. DOI: 10.1016/j.jacc.2012.04.062
  9. Biondi-Zoccai G.G., Lotrionte M., Agostoni P., et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. European Heart Journal. 2006; 27: 2667–674. DOI: 10.1093/eurheartj/ehl334
  10. Mehran R., Baber U., Steg P.G., et al. Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet. 2013; 382: 1714–1722. DOI: 10.1016/S0140-6736(13)61720-1
  11. Rossini R., Musumeci G., Capodanno D., et al. (2015) Perioperative management of oral antiplatelet therapy and clinical outcomes in coronary stent patients undergoing surgery. Results of a multicentre registry. Thromb. Haemost. 2015; 113: 272–282. DOI: 10.1160/TH14-05-0436
  12. Corredor C., Wasowicz M., Karkouti K., Sharma V. The role of point-of-care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta-analysis. Anaesthesia. 2015; 70, 715–731. DOI: 10.1111/anae.13083
  13. Колесникова И.М., Ройтман Е.В. Новый метод определения гемостатической способности тромбоцитов на основе тромбоэластографии. Тромбоз, гемостаз и реология. 2016; 67(S3): 203–204.
  14. [Kolesnikova I.M., Rojtman E.V. Novyj metod opredeleniya gemostaticheskoj sposobnosti trombocitov na osnove tromboehlastografii. Tromboz, gemostaz i reologiya. 2016; 67(S3): 203–204. (In Russ)]
  15. Kasivisvanathan R., Abbassi-Ghadi N., Kumar S., et al. Risk of bleeding and adverse outcomes predicted by thromboelastography platelet mapping in patients taking clopidogrel within 7 days of non-cardiac surgery. British Journal of Surgery. 2014; 101: 1383–1390. DOI: 10.1002/bjs.9592
  16. Sousa-Uva M., Storey R., Huber K., et al. Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery. European Heart Journal. 2014; 35: 1510–1514. DOI: 10.1093/eurheartj/ehu158
  17. Lip G.Y., Nieuwlaat R., Pisters R., et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010; 137(2): 263–272. DOI: 10.1378/chest.09-1584
  18. Kolh Ph., Wijns W., Danchin N., et al. Guidelines on myocardial revascularization. Eur. J. Cardiothorac. Surg. 2010; 38(Suppl.): 1–52. DOI: 10.1016/j.ejcts.2010.08.019
  19. Douketis J.D. Perioperative anticoagulation management in patients who are receiving oral anticoagulant therapy: A practical guide for clinicians. Thromb. Res. 2002; 108: 3–13.
  20. Schulman S., Hwang H.G., Eikelboom J.W., et al. Loading dose vs. maintenance dose of warfarin for reinitiation after invasive procedures: a randomized trial. Journal of Thrombosis and Haemostasis. 2014; 12: 1254–1259. DOI: 10.1111/jth.12613
  21. Dunn A.S., Turpie A.G. Perioperative management of patients receiving oral anticoagulants: a systematic review. Archives of Internal Medicine. 2003; 163: 901–908. DOI: 10.1001/archinte.163.8.901
  22. Dunn A.S., Spyropoulos A.C., Turpie A.G. Bridging therapy in patients on longterm oral anticoagulants who require surgery: the Prospective Peri-operative Enoxaparin Cohort Trial (PROSPECT). Journal of Thrombosis and Haemostasis. 2007; 5: 2211–2218. DOI: 10.1111/j.1538-7836.2007.02729.x
  23. Dentali F., Pignatelli P., Malato A., et al. Incidence of thromboembolic complications in patients with atrial fibrillation or mechanical heart valves with a subtherapeutic international normalized ratio: a prospective multicenter cohort study. American Journal of Hematology. 2012; 87: 384–387.
  24. Douketis J.D., Spyropoulos A.C., Spencer F.A., et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed.: American College of Chest Physicians Evidence- Based Clinical Practice Guidelines. Chest. 2012; 141: e326S–e350S. DOI: 10.1378/chest.11-2298
  25. Siegal D., Yudin J., Kaatz S., et al. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation. 2012; 126: 1630–1639. DOI: 10.1161/circulationaha.112.1052
  26. Spyropoulos A.C., Douketis J.D. How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood. 2012; 120: 2954–2962. DOI: 10.1182/blood-2012-06-415943
  27. Kearon C., Akl E.A. Duration of anticoagulant therapy for deep vein thrombosis and pulmonary embolism. Blood. 2014; 123: 1794–1801. DOI: 10.1182/blood-2013-12-512681
  28. Sherwood M.W., Douketis J.D., Patel M.R., et al. Outcomes of temporary interruption of rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation: results from the rivaroxaban once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation (ROCKET AF). Circulation. 2014; 129, 1850–1859. DOI: 10.1161/circulationaha.113.005754
  29. Lai A., Davidson N., Galloway S.W., Thachil J. Perioperative management of patients on new oral anticoagulants.[Erratum appears in Br J Surg. 2014 Nov; 101(12): 1624]. British Journal of Surgery. 2014; 101: 742–749.
  30. Heidbuchel H., Verhamme P., Alings M., et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with nonvalvular atrial fibrillation. Europace. 2015; 17, 1467–1507.
  31. Lecompte T, Hardy J. Antiplatelet agents and perioperative bleeding. Canadian Journal of Anaesthesia. 2006; 53: S103–S112.
  32. Kozek-Langenecker S.A., Ahmed A.B., Afshari A., et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur. J. Anaesthesiol. 2017; 34: 332–395. DOI: 10.1097/EJA.0000000000000630
  33. Rossaint R. et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Critical Care. 2016; 20: 100. DOI: 10.1186/s13054-016-1265-x
  34. Refaai M.A., Goldstein J.N., Milling T.J., et al. Randomized phase IIIb study of rapid vitamin K antagonist reversal in patients requiring an urgent surgical procedure: Four-factor prothrombin complex concentrate is superior to plasma. Blood (ASH Annual Meeting Abstracts). 2013; 122: 3588.
  35. Goldstein J.N., Refaai M.A., Milling T.J., et al. Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. Lancet. 2015; 385: 2077–2087. DOI: 10.1016/S0140-6736(14)61685-8
  36. Eikelboom J.W., Kozek-Langenecker S., Exadaktylos A., et al. Emergency care of patients receiving non-vitamin K antagonist oral anticoagulation. British Journal of Anesthesia. 2018; 120(4): 645–656. DOI: 10.1016/j.bja.2017.11.082
  37. American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task force on perioperative blood management. Anesthesiology. 2015; 122: 241–275. DOI: 10.1097/ALN.0000000000000463
  38. Chang D.N., Dager W.E., Chin A.I. Removal of dabigatran by hemodialysis. American Journal of Kidney Diseases. 2013; 61: 487–489. DOI: 10.1053/j.ajkd.2012.08.047
  39. Chai-Adisaksopha C., Hillis C., Lim W., et al. Hemodialysis for the treatment of dabigatran associated bleeding: a case report and systematic review. Journal of Thrombosis and Haemostasis. 2015; 13: 1790–1798. DOI: 10.1111/jth.13117
  40. Vilahur G., Choi B.G., Zafar M.U., et al. Normalization of platelet reactivity in clopidogrel-treated subjects. Journal of Thrombosis & Haemostasis. 2007; 5: 82–90.
  41. Li C., Hirsh J., Xie C., et al. Reversal of the anti-platelet effects of aspirin and clopidogrel. Journal of Thrombosis and Haemostasis. 2012; 10: 521–528.
  42. Thiele T., Sumnig A., Hron G., et al. Platelet transfusion for reversal of dual antiplatelet therapy in patients requiring urgent surgery: a pilot study. Journal of Thrombosis and Haemostasis. 2012; 10: 968–971.
  43. Llau J.V., De Andres J., Gomar C., et al. Anticlotting drugs and regional anaesthetic and analgesis technigues: comparative update of the safety recommendatios. European Journal of Anaesthesiology. 2007; 24: 387–398.