Search

The decision to continue or to stop oral anticoagulant therapy in the peri-interventional period is based on the evaluation of bleeding risk associated with the invasive procedure or with the anaesthetic technique, especially when a deep nerve block or a neuraxial block is planned, and on the evaluation of patient-associated risk factors. Anticoagulant bridging during the preoperative period as well as an early resumption of anticoagulation in the postoperative period are associated with increased bleeding rates without reduction of thromboembolic events, thus limiting the indications of bridging to patients with chronic vitamin K agonist therapy and a high thrombotic risk.La décision de poursuivre ou d’arrêter un traitement anticoagulant oral en période péri-interventionnelle se base sur l’évaluation du risque hémorragique en lien avec le geste invasif ou la technique anesthésique, en particulier lorsqu’une anesthésie locorégionale profonde ou neuraxiale est envisagée, et sur l’évaluation des pathologies du patient. Un relais anticoagulant en préopératoire, tout comme la reprise précoce de l’anticoagulation en postopératoire, expose le patient à un risque hémorragique qui, le plus souvent, surpasse le risque thrombotique, limitant l’indication des relais anticoagulants aux patients traités par antivitamine K au long cours et à haut risque thrombotique.

Le Groupe d’intérêt en hémostase périopératoire (GIHP) et le Groupe français d’études sur l’hémostase et la thrombose (GFHT), en collaboration avec la Société française d’anesthésie et de réanimation (SFAR) ont fait des propositions de gestion des agents antiplaquettaires (AAP) pour une procédure invasive programmée. Ces propositions ont été discutées et validées par vote ; toutes sauf une ont fait l’objet d’un accord fort. La gestion des AAP dépend de leur indication et de la procédure considérée. Le risque hémorragique lié à la procédure invasive peut être divisé en bas, intermédiaire ou élevé, selon la possibilité ou non de réaliser la procédure sous traitement (sous respectivement bithérapie antiplaquettaire, aspirine en monothérapie ou aucun AAP). Si une interruption des AAP est indiquée avant la procédure, une dernière prise d’aspirine, clopidogrel, ticagrélor et prasugrel 3, 5, 5 et 7 jours avant la procédure est proposée. Le risque thrombotique associé à l’interruption des AAP doit être évalué en fonction de l’indication des AAP. Il est plus élevé chez les patients traités par bithérapie pour un stent coronaire que chez ceux traités par monothérapie pour une prévention cardiovasculaire, un antécédent d’accident vasculaire cérébral ischémique ou une artériopathie oblitérante des membres inférieurs. Ces propositions concernent aussi le rôle potentiel des tests fonctionnels plaquettaires, la gestion des AAP pour l’anesthésie locorégionale, centrale et périphérique, et pour la chirurgie cardiaque coronaire.

Heparin-induced thrombocytopenia (HIT) is a rare, iatrogenic disease characterised by its potential severity, mainly related to thrombosis, and by difficulties regarding its diagnosis and management of affected patients. In 2002, a conference of experts mobilised by the French Society of Anaesthesia and Intensive Care Medicine (Société française d’anesthésie et de réanimation [SFAR]) drafted recommendations for the management of HIT [...]

Resume Le Groupe d’interet en hemostase perioperatoire (GIHP) et le Groupe francais d’etudes sur l’hemostase et la thrombose (GFHT), en collaboration avec la Societe francaise d’anesthesie-reanimation (SFAR) ont fait des propositions de gestion des agents antiplaquettaires (AAP) pour une procedure invasive programmee. Ces propositions ont ete discutees et validees par vote ; toutes sauf une ont fait l’objet d’un accord fort. La gestion des AAP depend de leur indication et de la procedure consideree. Le risque hemorragique lie a la procedure invasive peut etre divise en bas, intermediaire ou eleve, selon la possibilite ou non de realiser la procedure sous traitement (sous respectivement bitherapie antiplaquettaire, aspirine en monotherapie ou aucun AAP). Si une interruption des AAP est indiquee avant la procedure, une derniere prise d’aspirine, clopidogrel, ticagrelor et prasugrel 3, 5, 5 et 7 jours avant la procedure est proposee. Le risque thrombotique associe a l’interruption des AAP doit etre evalue en fonction de l’indication des AAP. Il est plus eleve chez les patients traites par bitherapie pour un stent coronaire que chez ceux traites par monotherapie pour une prevention cardiovasculaire, un antecedent d’accident vasculaire cerebral ischemique ou une arteriopathie obliterante des membres inferieurs. Ces propositions concernent aussi le role potentiel des tests fonctionnels plaquettaires, la gestion des AAP pour l’anesthesie locoregionale, centrale et peripherique, et pour la chirurgie cardiaque coronaire.

BACKGROUND Prasugrel is a thienopyridine that inhibits platelet aggregation more rapidly and effectively than clopidogrel, with an increased bleeding risk. OBJECTIVE The current study aimed to evaluate the efficacy of three nonspecific haemostatic drugs - recombinant activated factor VII (rFVIIa), tranexamic acid and desmopressin (DDAVP) - to limit blood loss after administration of prasugrel in a rabbit model of bleeding while also evaluating any prothrombotic effects. DESIGN Randomised, placebo-controlled study. SETTING Faculty of Medicine, University of Geneva, Switzerland, in 2013. ANIMALS Anaesthetised and artificially ventilated rabbits (n=56). INTERVENTIONS Animals were randomly allocated to one of five groups: control (placebo-placebo), prasugrel-placebo, rFVIIa (prasugrel-rFVIIa 150 μg kg), tranexamic acid (prasugrel-tranexamic acid 20 mg kg) or DDAVP (prasugrel-DDAVP 1 μg kg). Two hours after an oral prasugrel loading dose (4 mg kg), a stenosis and an injury were inflicted on the carotid artery to induce cyclic flow reductions (CFRs) due to thrombosis. Haemostatic drugs were administered during the ensuing observation period. MAIN OUTCOME MEASURES Standardised hepatosplenic sections were performed to evaluate the primary endpoint of blood loss, monitored for 15 min. Ear-immersion bleeding time and incidence of CFRs were secondary endpoints. RESULTS Prasugrel decreased ADP-induced platelet aggregation (light transmission method) from 66 ± 4% (mean ± SD) to 41 ± 7% (P

Resume Depuis 2011, l’experience et les donnees concernant les patients traites par anticoagulants oraux directs (AOD) et beneficiant d’un acte invasif programme se sont enrichies. Dans le meme temps, un accroissement du risque hemorragique lors de la realisation de relais anticoagulants preoperatoires a ete mis en evidence, sans reduction du risque thrombotique. Ces donnees nouvelles conduisent a adapter les propositions emises par le GIHP en 2011. Pour les actes programmes a risque hemorragique faible, il est propose de ne pas prendre d’AOD la veille au soir ni le matin de l’intervention, quel que soit le schema therapeutique du patient ; et de reprendre le traitement selon le schema habituel du patient et au moins 6 heures apres la fin du geste invasif. Pour les actes invasifs a risque hemorragique eleve, il est propose une derniere prise a j–3 pour le rivaroxaban, l’apixaban et l’edoxaban ; une derniere prise de dabigatran a j–4 si la clairance de la creatinine est superieure a 50 mL/min, a j–5 si la clairance est comprise entre 30 et 50 mL/min. Dans le cas de la neurochirurgie intracrânienne et de l’anesthesie neuraxiale, des delais plus longs sont conseilles. Il n’y a plus de place pour les relais anticoagulants ni pour la mesure des concentrations d’AOD sauf situations exceptionnelles.

The French Working Group on Perioperative Haemostasis (GIHP)and the French Study Group on Haemostasis and Thrombosis (GFHT)in collaboration with the French Society of Anaesthesia and Intensive Care Medicine (SFAR)drafted up-to-date proposals on the management of antiplatelet therapy for non-elective invasive procedures or bleeding complications. The proposals were discussed and validated by a vote; all proposals could be assigned with a high strength. Emergency management of oral antiplatelet agents (APA)requires knowledge on their pharmacokinetic/pharmacodynamics parameters, evaluation of the degree of the alteration of haemostatic competence and the associated bleeding risk. Platelet function testing may be considered. When APA-induced bleeding risk may worsen the prognosis, measures should be taken to neutralise antiplatelet therapy by considering not only the efficacy of available means (which can be limited for prasugrel and even more for ticagrelor)but also the risks that these means expose the patient to. The measures include platelet transfusion at the appropriate dose and haemostatic agents (tranexamic acid; rFVIIa for ticagrelor). When possible, postponing non-elective invasive procedures at least for a few hours until the elimination of the active compound (which could compromise the effect of transfused platelets)or if possible a few days (reduction of the effect of APA)should be considered., SCOPUS: ar.j, info:eu-repo/semantics/published

The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT), in collaboration with the French Society for Anaesthesia and Intensive Care (SFAR), drafted up-to-date proposals on the management of antiplatelet therapy for non-elective invasive procedures or bleeding complications. The proposals were discussed and validated by a vote; all proposals could be assigned with a high strength. Management of oral antiplatelet agents in emergency settings requires knowledge of their pharmacokinetic and pharmacodynamic parameters, evaluation of the degree of alteration of haemostatic competence and the associated bleeding risk. Platelet function testing may be considered. When antiplatelet agent-induced bleeding risk may worsen the prognosis, measures should be taken to neutralize antiplatelet therapy, by considering not only the efficacy of available means (which can be limited for prasugrel and even more for ticagrelor), but also the risks that these means expose the patient to. The measures include platelet transfusion at the appropriate dose and haemostatic agents (tranexamic acid; recombinant activated factor VII for ticagrelor). When possible, postponing non-elective invasive procedures at least for a few hours until the elimination of the active compound (which could compromise the effect of transfused platelets) or, if possible, for a few days (reduction of the effect of antiplatelet agents) should be considered.

International audience

The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals for the management of antiplatelet therapy in patients undergoing elective invasive procedures. The proposals were discussed and validated by a vote; all proposals but one could be assigned with a high strength. The management of antiplatelet therapy is based on their indication and the procedure. The risk of bleeding related to the procedure can be divided into high, moderate and low categories depending on the possibility of performing the procedure in patients receiving antiplatelet agents (none, monotherapy and dual antiplatelet therapy respectively). If discontinuation of antiplatelet therapy is indicated before the procedure, a last intake of aspirin, clopidogrel, ticagrelor and prasugrel 3, 5, 5 and 7 days before surgery respectively is proposed. The thrombotic risk associated with discontinuation should be assessed according to each specific indication of antiplatelet therapy and is higher for patients receiving dual therapy for coronary artery disease (with further refinements based on a few well-accepted items) than for those receiving monotherapy for cardiovascular prevention, for secondary stroke prevention or for lower extremity arterial disease. These proposals also address the issue of the potential role of platelet functional tests and consider management of antiplatelet therapy for regional anaesthesia, including central neuraxial anaesthesia and peripheral nerve blocks, and for coronary artery surgery., SCOPUS: ar.j, info:eu-repo/semantics/published

Purpose: Viscoelastic tests (VETs), thromboelastography (TEG®) and thromboelastometry (ROTEM®) are global tests of coagulation performed on whole blood. They evaluate the mechanical strength of a clot as it builds and develops after coagulation itself. The time required to obtain haemostasis results remains a major problem for clinicians dealing with bleeding, although some teams have developed a rapid laboratory response strategy. Indeed, the value of rapid point-of-care diagnostic devices such as VETs has increased over the years. However, VETs are not standardised and there are few recommendations from the learned societies regarding their use. In 2014, the recommendations of the International Society of Thrombosis and Haemostasis (ISTH) only concerned haemophilia. The French Working Group on Perioperative haemostasis (GIHP) therefore proposes to summarise knowledge on the clinical use of these techniques in the setting of emergency and perioperative medicine. Methods: A review of the literature. Principal findings: The role of the VETs seems established in the management of severe trauma and in cardiac surgery, both adult and paediatric. In other situations, their role remains to be defined: hepatic transplantation, postpartum haemorrhage, and non-cardiac surgery. They must be part of the global management of haemostasis based on algorithms defined in each centre and for each population of patients. Their position at the bedside or in the laboratory is a matter of discussion between clinicians and biologists. Conclusion: VETs must be included in algorithms. In consultation with the biology laboratory, these devices should be situated according to the way each centre functions., SCOPUS: ar.j, info:eu-repo/semantics/published

Prasugrel and ticagrelor are next-generation antiplatelet agents that provide a rapider and more potent inhibition of platelet P2Y12 receptor than clopidogrel. In combination with aspirin, these new P2Y12 inhibitors are now the first line treatments for patients with acute coronary syndrome. However, these potent antiplatelet agents introduce a new paradigm in the daily management of antithrombotic drugs, particularly when an invasive procedure is planned. The pharmacology of these antiplatelet agents, and the results of the main clinical trials, are reviewed with a special focus on good prescription practices (indications, contra-indications, drug interactions), and on peri-operative management. Strategies are proposed for safely reducing the bleeding risk in elderly patients, in patients requiring concomitant oral anticoagulant therapy, or in patients with an increased haemorrhagic risk.

The large majority of patients undergoing ophthalmic surgery are elderly and take systemic medications on a regular basis, including antiplatelet and anticoagulant treatments. It is current practice for many physicians to discontinue antithrombotic treatment prior to surgery to reduce bleeding complications that may lead to retrobulbar haemorrhage and, ultimately, to loss of vision. However, discontinuation of antithrombotic treatment in such patients may lead to thromboembolic events with serious consequences. The present narrative review highlights the risk of thrombosis when discontinuing antithrombotic drugs and the risk of bleeding when continuing them. The published literature on this topic shows that discontinuation of antiplatelet or anticoagulant treatment leads to a substantially increased risk of arterial or venous thromboembolic events and related complications, especially in patients with atrial fibrillation, prosthetic heart valves or recent coronary stenting. This risk is distinctly higher than the risk of significant local haemorrhage. Ophthalmic bleeding events reported in the literature are usually minor, without serious consequences, even if antiplatelet or anticoagulant treatments are continued, provided that the anticoagulation level is within the therapeutic range. Thus, the current data are in favour of maintaining antiplatelet and anticoagulant drugs for most ophthalmic procedures, regardless of the anaesthetic techniques.

Resume Le bilan d’hemostase standard est encore largement prescrit a titre systematique avant une intervention chirurgicale ou une procedure invasive (geste endoscopique, anesthesie neuraxiale) pour evaluer le risque hemorragique perioperatoire. Pourtant la capacite du bilan d’hemostase (temps de cephaline avec activateur, temps de Quick, numeration plaquettaire) a predire le risque hemorragique perioperatoire est mauvaise, et la realisation d’un tel bilan ne modifie que tres rarement la prise en charge des patients. Les recommandations des differentes societes, publiees ces dernieres annees, sont de ne pas prescrire de bilan d’hemostase chez les patients dont l’interrogatoire et l’examen clinique ne font pas suspecter un trouble de l’hemostase. L’appreciation des capacites hemostatiques du patient doit se baser essentiellement sur l’anamnese personnelle et familiale de diathese hemorragique et les antecedents chirurgicaux ou traumatiques. Le bilan biologique d’hemostase doit etre reserve aux patients dont l’anamnese fait suspecter une pathologie de l’hemostase augmentant le risque hemorragique, aux patients dont l’anamnese est impossible ou non contributive, aux patients avec une pathologie de l’hemostase connue, et aux quelques situations necessitant des valeurs de reference preoperatoires.

Prasugrel provides rapid and intense inhibition of platelet aggregation combined with an increased risk of bleeding. We evaluated the efficacy and safety of platelet transfusion to reduce blood loss after a prasugrel loading dose in a rabbit model.Thirty-five rabbits were randomized into five groups: "control" (saline plus physiological buffer), "no-transfusion" (prasugrel plus physiological buffer), "platelet low dose" (prasugrel loading dose plus transfusion with a platelet count increase80 × 10Blood loss in the "control" group was 3.16 g/kg (inerquartile range [IQR] [2.87-4.89]) and was increased in the "no-transfusion" group to 6.15 g/kg (IQR [4.79-9.15]; p 0.02). There was a gradual trend across the three transfusion groups toward less bleeding, and the highest dose of platelet transfusion significantly decreased prasugrel-induced blood loss (3.05 g/kg; IQR [2.55-3.56]; p = 0.006). Platelet aggregation was significantly but only partially restored in the latter group. Regarding safety, platelet transfusion was not associated with an increase in thrombotic events regardless of the dose.In this animal model, platelet transfusion aiming for a platelet count increase of at least 120 × 10

Current recommendations for the assessment of the risk of perioperative bleeding limit coagulation testing to patients with a personal and/or family history of bleeding. As no simple preoperative screening questionnaire is currently available, we assessed the performance of a novel screening questionnaire for its ability to detect bleeding disorders.A dichotomized, seven-point questionnaire named HEMSTOP (Hematoma, hEmorrhage, Menorrhagia, Surgery, Tooth extraction, Obstetrics, Parents) was applied to three groups of subjects: patients referred to hemostasis specialists for bleeding symptoms for whom any kind of perioperative hemostatic precautions were subsequently recommended (n = 38); patients referred to hemostasis specialists for whom precautions were not required (n = 75); healthy volunteers (n = 70). We calculated the sensitivity and specificity of HEMSTOP scores and compared them with the discriminative performances of standard blood coagulation assays (prothrombin time, activated partial thromboplastin time).Patients requiring perioperative hemostatic precautions had greater median [interquartile range] HEMSTOP scores (2 [2-3]) than patients not requiring precautions (1 [1-2]) and healthy controls (0 [0-0]); P0.001. A HEMSTOP score ≥ 2 had a specificity of 98.6% [95% confidence interval (CI), 92.3 to 100] and a sensitivity of 89.5% (95% CI, 75.2 to 97.1). The 26.3% (95% CI, 13.4 to 43.1) sensitivity of the standard coagulation times was much lower.The HEMSTOP score discriminates patients at an elevated risk for bleeding with recommended perioperative precautions from those without such recommendations as well as from healthy participants. Further evaluation of the HEMSTOP score is required for a better evaluation of its definitive usefulness to predict the risk of perioperative bleeding.

SummaryBackground Systematic preoperative coagulation testing is still widely used in children scheduled for surgery, although current guidelines recommend that a bleeding history should be the first choice for hemostatic assessment. We performed a systematic review with meta-analysis to evaluate the pertinence of bleeding questionnaire and screening laboratory testing to detect bleeding disorders (BDs) in children and to predict abnormal surgical blood loss. Methods A search was conducted in PubMed, EMBASE, MEDLINE(R), Cochrane Central Register of Controlled Trials, Health technology Assessment, and all EBM Reviews (Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED and EBM Reviews) up to October 22, 2013. Prospective trials containing 20 children or more and any tests evaluating either the ability of the test to detect a congenital BD or the ability of the test to predict increased surgical blood loss were retained. The quality of the study was judged with the Cochrane Collaboration Tool and two investigators extracted data independently. Data were combined to calculate the pooled diagnostic odds ratio (DOR) and their 95% confidence intervals (CI 95%). I2 statistics were used to assess statistics heterogeneity. Results Data could be extracted from 16 studies. Best results for detecting a congenital abnormality at potential risk for increased surgical blood loss were obtained with the PFA-100 (DOR = 113.0; 95% CI, 22.6–566.2; I2 = 0%) in two studies, followed by the bleeding time in two other studies (DOR = 110.7; 95% CI, 24.4–502.3; I2 = 0%). With a high amount of heterogeneity, questionnaires showed disappointing performances (DOR = 7.9; 95% CI: 3.5–17.5; I2 = 72.6%). Conclusion Current evidence does not identify a tool that adequately predicts BDs and/or abnormal surgical blood loss in children. Questionnaires currently available do not perform well. In the setting of a pediatric coagulation clinic, the PFA-100 has the highest chance of detecting a BD. This meta-analysis highlights the weakness of the literature regarding the prediction of perioperative bleeding due to congenital hemostatic disorders in children.

We describe a case of a 67-year-old man who required emergency surgery for acute intracranial bleeding after having received a loading dose of aspirin and ticagrelor for an acute ST-elevation myocardial infarction. Before and during the craniocervical decompression, the assessment of platelet function was performed using the Multiplate® analyzer. Biological evaluation of platelet function was consistent with the clinical impression, suggesting that platelet transfusion and desmopressin administration in the presence of ticagrelor had very little, if any, hemostatic effect.

Managing bleeding in patients receiving P2Y12 inhibitors is challenging. Few data are available regarding the efficacy of platelet transfusion in patients treated with prasugrel or ticagrelor. The aim of this study was to evaluate the minimal amount of platelet supplementation (in terms of ratio of non-inhibited platelets to inhibited platelets) necessary to restore platelet reactivity in platelet-rich plasma (PRP) of patients treated with aspirin and a prasugrel or ticagrelor loading dose for an acute coronary syndrome. PRP samples from patients were mixed ex vivo with increasing proportions of pooled PRP from healthy volunteers. Platelet reactivity was challenged with adenosine diphosphate (ADP), arachidonic acid, collagen or thrombin receptor activating peptide using light transmission aggregometry. The primary endpoint was the proportion of patient samples recovering an ADP-induced maximal aggregation (ADP-Aggmax) value above 40%. In patients treated with prasugrel (n = 32), ADP-Aggmax increased progressively with supplements of pooled PRP, with an average increase of 7.9% (95% CI [7.1; 8.8], p

Haemodynamic goal-directed therapies (GDT) may improve outcome following elective major surgery. So far, few data exist regarding haemodynamic optimization during emergency surgery. In this randomized, controlled trial, 50 surgical patients with hypovolemic or septic conditions were enrolled and we compared two algorithms of GDTs based either on conventional parameters and pressure pulse variation (control group) or on cardiac index, global end-diastolic volume index and stroke volume variation as derived from the PiCCO monitoring system (optimized group). Postoperative outcome was estimated by a composite index including major complications and by the Sequential Organ Failure Assessment (SOFA) Score within the first 3 days after surgery (POD1, POD2 and POD3). Data from 43 patients were analyzed (control group, N = 23; optimized group, N = 20). Similar amounts of fluid were given in the two groups. Intraoperatively, dobutamine was given in 45 % optimized patients but in no control patients. Major complications occurred more frequently in the optimized group [19 (95 %) versus 10 (40 %) in the control group, P

Hemostasis is the result of a complex interaction between vessels, platelets, and coagulation proteins that stops bleeding (primary hemostasis, coagulation) while maintaining blood flow in the vessel (fibrinolysis).

Direct oral anticoagulants, anti-Xa and anti-IIa, are indicated in case of atrial fibrillation or venous thromboembolic disease. Annually, one in ten patients treated by anticoagulants required a scheduled or emergent invasive procedure. Short discontinuation before an invasive procedure may lead to incomplete elimination of the drug especially in case of renal insufficiency or drug-drug interactions. Before an invasive procedure with a moderate to high bleeding risk, a discontinuation of 5 days is proposed, most often without bridging with heparin. Before a procedure with a low bleeding risk, stopping direct anticoagulant 24 hours before the procedure is sufficient. In case of emergent surgery, it is proposed to delay surgery for at least one or two half-lives if possible. Prophylactic use of non-specific procoagulant drug is not recommended.