New approaches on diagnosis and treatment of venous thromboembolism

Summary Pulmonary embolism (PE) and deep vein thrombosis (DVT) are two clinical presentations of venous thromboembolism (VTE) and share the same predisposing factors. In patients admitted to a hospital the rationale use of thromboprophylaxis is based on the high prevalence of VTE amongst hospitalised patients, the adverse consequences of unprevented VTE, and the efficacy of thromboprophylaxis. There is no doubt about the benefit/risk ratio of perioperative venous thromboembolism prophylaxis, but for a safety performance of regional anaesthesia, particularly neuraxial blocks, an appropriate management based on safety intervals suited to the characteristics of the drug is needed. The first st…

Manejo perioperatorio de los anticoagulantes orales directos en cirugía urgente y sangrado. Monitorización y tratamiento hemostático

There is an almost unanimous consensus on the management of the direct new oral anticoagulants, dabigatran, rivaroxaban, and apixaban in elective surgery. However, this general consensus does not exist in relation with the direct new oral anticoagulants use in emergency surgery, especially in the bleeding patient. For this reason, a literature review was performed using the MEDLINE-PubMed. An analysis was made of the journal articles, reviews, systematic reviews, and practices guidelines published between 2000 and 2014 using the terms "monitoring" and "reversal". From this review, it was shown that the routine tests of blood coagulation, such as the prothrombin time and activated partial th…

Recomendaciones de manejo perioperatorio de antiagregantes plaquetarios en cirugía no cardíaca. Grupo de trabajo de la Sección de Hemostasia, Medicina Transfusional y Fluidoterapia de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR). Actualización de la Guía de práctica clínica 2018

Perioperative and Periprocedural Management of Antithrombotic Therapy: Consensus Document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEU

During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patient's thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most o…

Neurally adjusted ventilatory assist: An update

Summary Neurally adjusted ventilatory assist (NAVA) is a new ventilation mode that provides a proportional assistance to the inspiratory effort of the patients. It is based on the use of the diaphragm electromyographic activity (Edi) for the control of the ventilation assistance. The ability of NAVA to improve the limitations of the conventional assisted ventilator modes has been assessed in clinical studies and discussed in this report, as the latest applications of NAVA in children and non-invasive ventilation, due to the improvement of the patient–ventilator interactions delivered by NAVA. We also review the most recent literature on a new trend to use the Edi as a predictor of weaning s…

Manejo de los anticoagulantes orales de acción directa en el período perioperatorio y técnicas invasivas

The new direct-acting oral anticoagulants (ACOD) in patients on prolonged treatment require the need to balance the risk of haemorrhage by administering them against the risk of thrombosis on withdrawing them. Recommendations for their management are proposed in the present article: A) Thromboprophylaxis and general anaesthesia: the performing of regional anaesthesia if administered with an ACOD as thromboprophylaxis requires some safety intervals based on their pharmacokinetic parameters; B) Management of ACOD in elective surgery: in patients with normal renal function and a low haemorrhage/thrombosis risk, stop the ACOD two days before the surgery; it the haemorrhage/thrombosis risk is hi…

Recomendaciones de uso de los anticoagulantes orales directos en el período perioperatorio

Because of the characteristics of direct oral anticoagulants (DOA), the lack of an antidote to completely reverse their anticoagulant effects, the absence of standardization in monitoring of their effects, and limited experience of their use, specific recommendations for their management in the perioperative period or in emergencies are required. In elective surgery, in patients with normal renal function and low hemorrhagic/ thrombotic risk, DOA should be withdrawn 2 days before the intervention; when the hemorrhagic/ thrombotic risk is higher, bridge therapy with a low molecular weight hepatin beginning 5 days before the intervention is proposed as an alternative. In emergency surgery, sy…

Recommendations for perioperative antiplatelet treatment in non-cardiac surgery. Working Group of the Spanish Society of Anaesthesiology-Resuscitation and Pain Therapy, Division of Haemostasis, Transfusion Medicine, and Perioperative Fluid Therapy. Update of the Clinical practice guide 2018

Are Anticoagulants and Antiplatelet Agents Important in Thoracic Surgery?

The management of antithrombotic drugs (antiplatelet and anticoagulant agents) is a common challenging issue in patients undergoing thoracic surgery. The procedure can require the temporary interruption of these drugs because of their associated haemorrhagic risk, therefore assuming a thrombotic risk also. The assessment of the balance between both risks gives us their optimal management.

Antiagregantes y anticoagulantes: manejo del paciente quirúrgico anticoagulado

Resumen Entre los grupos farmacologicos de mayor consumo por los pacientes se encuentran tanto los antiagregantes plaquetarios (aspirina, clopidogrel, ticlopidina) como los anticoagulants (acenocumarol, warfarina, heparina de bajo peso molecular, fondaparinux). El manejo de los mismos en el periodo perioperatorio constituye uno de los aspectos esenciales en el cuidado de los pacientes debido a la necesidad de equilibrar adecuadamente el riesgo de sangrado frente al riesgo trombotico (arterial o venoso) que se incrementa en los pacientes quirurgicos. En la presente revision se destacan tres aspectos esenciales. En primer lugar, respecto a los antiagregantes plaquetarios, es habitual que se r…