華法林治療的患者接受侵入性檢查和手術(shù)期間的管理指南

1、Warfarin Therapy Management During Invasive Procedures and Surgery,急診外科 張 榮,,,ScopeKey RecommendationsRisksManagement,,ScopeKey RecommendationsRisksManagement,Scope,This guideline provides recommendations for t

2、he management of warfarin therapy in adults aged ≥ 19 years requiring invasive procedures and surgery.Perioperative management of non-vitamin K antagonist oral anticoagulants can be found in BCGuidelines.ca – Use of NOA

3、Cs in Non-Valvular Atrial Fibrillation. Non-perioperative management of warfarin is covered in BCGuidelines.ca – Warfarin Therapy Management.,,ScopeKey RecommendationsRisksManagement,Key Recommendations,? Warfarin di

4、scontinuation prior to invasive procedures is necessary for all interventional procedures except for minor skin procedures, routine dental work, cataract surgery, endoscopies without biopsy, and percutaneous venous acces

5、s.? For elective procedures, warfarin should be stopped for 5 to 6 days prior to the procedure to allow gradual normalization of the international normalized ratio (INR).? For urgent procedures, use of prothrombin comp

6、lex concentrate is highly effective in rapidly reversing warfarin anticoagulant activity and has a duration of action of ~ 6 hours.? The use of bridging heparin therapy is dependent on the risk of thrombosis.? Discuss

7、the risk of bleeding with the surgeon and anesthesiologist to determine optimal timing for resuming warfarin and bridging heparin therapy after surgery.,,ScopeKey RecommendationsRisksManagement,Risks,The management of

8、 warfarin therapy in patients undergoing surgery or other invasive procedures involves a fine balance between the risk of hemorrhage if the procedure was performed while on warfarin, and the risk of thrombosis if warfari

9、n was discontinued. The thrombotic risk in the perioperative period depends on pre-existing conditions, the time since the last episode of thrombosis, and the thrombotic effect of surgery.The risk of hemorrhage in th

10、e perioperative period depends on the patient’s age, associated medical conditions, type of procedure, approach, site, type of incision and closure, and the method of administration of anesthesia and analgesia. It is rec

11、ommended that the anesthesiologist and the surgeon be consulted in determining the hemorrhagic risk,Risks,Preoperative management of warfarin therapy consists of timely discontinuation of warfarin and replacement (known

12、as “bridging”) with therapeutic low molecular weight heparin (LMWH) or unfractionated heparin if the risk of thrombosis is considered to be sufficiently high. Almost all patients will achieve an international normalized

13、 ration (INR) of 70 years) will require a longer period of warfarin withdrawal before surgery. Patients with a high risk of thromboembolism or stroke may benefit from bridging with heparin during the preoperative perio

14、d, either as outpatients (LMWH subcutaneously) or inpatients (unfractionated heparin intravenously) by shortening the duration of subtherapeutic anticoagulation.,Risks,Postoperative management of warfarin therapy consist

15、s of re-initiation of anticoagulation. Postoperative anticoagulation increases the rate of major bleeding.Typically, warfarin can resume the evening of or next day after the procedure because the anticoagulant activity

16、is not established for several days. Restarting warfarin may be delayed in neurosurgical patients, those receiving epidural analgesia and in patients who are bleeding. For patients at high risk of thrombosis, LMWH by in

17、jection is given concurrently with warfarin and the overlap is maintained until a therapeutic INR has been reached. LMWH used postoperatively may allow earlier discharge of the patient compared with using unfractionated

18、 heparin.,Risks,If urgent or emergent procedures are to be undertaken in < 4-5 days and warfarin reversal is required, it may be satisfactory to give 1-2 mg of vitamin K orally in order to expedite the reversal proces

19、s. When reversal of anticoagulation is required within 6 hours, intravenous vitamin K and prothrombin complex concentrate (PCC) (e.g., Octaplex®, Beriplex®) is highly effective and is recommended over frozen p

20、lasma infusion .,,ScopeKey RecommendationsRisksManagement,Management,Management,Management,Management of Perioperative Anticoagulation,Procedures associated with high and low risk for bleeding,Pre-existing conditions

21、associated with higher and lower risk of thrombosis,Management of Perioperative Anticoagulation,Management of Perioperative Anticoagulation,,Management of Perioperative Anticoagulation,Management of Perioperative Anticoa