Supervisors info:
Παρασκευή Ματσώτα, Αναπληρώτρια Καθηγήτρια, Ιατρική, ΕΚΠΑ
Στυλιανή Κόκορη, Επίκουρη Καθηγήτρια, Ιατρική, ΕΚΠΑ
Σερένα Βαλσάμη, Επίκουρη Καθηγήτρια, Ιατρική, ΕΚΠΑ
Summary:
INTRODUCTION
The perioperative management of patients who are under anticoagulant treatment is a complex issue requiring the involvement of many medical fields. Not only is clear knowledge of mechanisms and coagulation’s arc hemostasis disorders is required but specific knowledge of fibrinolysis mechanisms as well. Hemostasis is a very complex procedure whose pathophysiological aim is the prevention of bleeding andmaintenance of normal blood flow. The basic coagulation aim is the conversion of soluble fibrinogen to insoluble fibrin which encircles and runs through the platelet plug. Later, fibroblasts penetrate and form a connective tissue in 7-10 days. Descriptively the process is referred as the coagulation cascade in which the intrinsic and extrinsic pathway is distinguished. The fibrinolysis mechanism mediates to balance blood clotting mechanisms and activates the clot lysis and restoration of normal blood flow. The central fibrinolysis enzyme is plasma. Hemostasis and fibrinolysis are maintained in a delicate balance with the action of:
The enzyme systems
The inhibitors and activators
The negative feedback mechanisms and self-regulation.
This balance disruption can lead to bleeding or thrombosis. For this reason, the antithrombotic treatment always involves the risk of serious adverse events; It requires preoperative assessment and individualized surgical approach of the patient who will be operated on. Also, the anesthesiologist will evaluate and decide which anesthesia technique is best-suited for the patient as well as the management of anticoagulation therapy. Surgeons and anesthetists aim is to weigh both the hemorrhagic and antithrombotic risk respectively. For this reason, the guidelines imposed by the European and Hellenic Society of Anaesthesiology must be followed.
PURPOSE – MATERIAL - METHOD
The present study examines the management of surgical patients who are under anticoagulation therapy in the perioperative period as to tailor personalized treatment over the problem of clotting or coagulation and fibrinolysis. Specifically it was examined if and in which way the recommendations and guidelines of the Hellenic Society of Anesthesiology were followed (HSA) over the surgical patients who are under anticoagulation therapy. The study took place during the period from 1/1/2015 to 3/3/2015 on D’UNIVERSITY SURGICAL CLINIK OF THE General University Hospital “ATTIKON” and methodically is a retrospective approach of 105 patients. For each patient a questionnaire is filled with collecting data under the examined parameters. The data was gathered from the medical records of the patients which have been kept in the file department of the General University Hospital “ATTIKON”. The anesthetic and surgical intervention was indicated in the perioperative period of hospitalization of these patients.
STATISTICAL ANALYSIS
As far as statistical analysis is concerned, mean and standard deviation were used to describe quantitative variables the absolute (N) and relative (%) frequencies were used to describe quality variables. The Pearson’s x2 or the Fisher’s exact test were used to compare ratios. For the comparison of quantitative variables between more than two groups of ANOVA was used. The levels of significance are bilateral and the statistical significance was set at 0,05. For the data analysis the SPSS 19.0 Statistical program was used.
RESULTS-DISCUSION
The results show that by statistical analysis in 105 patients receiving anticoagulation therapy prior to hospital for non-cardiac surgery (N=59 PATIENTS) rate of 56,2%. Of these patients 33,3% was modifying the anticoagulation therapy.
In detail 17,1% was discontinuation of antiplatelet therapy for 7-10 days prior to surgery and discontinuation of new oral anticoagulants 11,5% and stopping coumarin at 4,8%. Covering 80% with LMWH specifically Ivor 2.500 in 64,8 %. During the day of the surgery anticoagulation therapy was quenched at a rate of 93,3%. Whilst they were anticoagulated at a rate of 6,7% with LMWH and more specific with cleaxane 0,3mg (4,8%) and cleaxane 0,4mg (1,9%) because of emergency surgeries. Tirobifan was given in 2,9% as anticoagulation theatment (aggrastat).
The technique of Anesthesia was also General Anesthesia (79.4%) combined (General-Vegional) Anesthesia (15,7%) and Vegional Anesthesia (4,9%). It was found that during the anticoagulation treatment, the second postoperative day, was stopped at 13,2% of the patients, so that the third postoperative day the epidural catheter to be removed. The proportion of the patients who received anticoagulation with ally differed (p<0,001) during the first postoperative day compared with those who stopped the anticoagulation therapy the second and the third postoperative day. These results are consistent with the quidelines of the Hellenic Society of Anesthesiology and also the European Anesthesiology Society. As example we mention the interruption of the anticoagulant treatment after the extra dose of heparine LMWH the first postoperative day in order to remove the epidural catheter. The second postoperative day while administering a LMWH dose,10 to 12 hours after the removal of the catheter. The administration of LMWH namely sodium vemiparinis continue during our project until the patient’s disharge.
CONCLUSION
Patients who taking anticoagulants and undergoing surgery need optimal perioperative management by Surgeous and Anesthesiologists, so the surgery will be performed in safe. In this project, despite our small study sample and our personalized approach to patients we found that the guidelines of both the Hellenic and European Society of Anesthesiology were followed.
ETHICAL
Permission has been requested by the Scientific Council of General University Hospital “ATTIKON” to access medical records. Medical confidentiality was absolutely respected
Keywords:
Hemostasis, Fibrinolysis, Antiplatelet drugs, Thrombophilia, Antithrombotic threatment, Bleeding, Transfusion, Regional anesthesia, Guidelines of Anesthesiologists Society.
