Best practice & research. Clinical anaesthesiology
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Perioperative coagulation monitoring is the rational diagnostic basis for pro- and anti-thrombotic interventions in patients undergoing emergency and elective surgery. The main goal of perioperative monitoring of haemostasis is to increase safety of patients undergoing surgical procedures. Currently, there is a change in paradigm with (1) increasing implementation of evidence-based approach to preoperative patient evaluation with laboratory coagulation testing secondary to the results of the standardised bleeding history and (2) awareness of the limitations of routine coagulation tests to guide coagulation management in massive bleeding. ⋯ This innovative methodology triggers a trend towards an 'early goal-directed coagulation management' focussing on potent coagulation factor concentrates. Practicability, cost-effectiveness, safety and--above all--growing scientific evidence support this concept, and lively discussions among anaesthesiologists and various medical disciplines may help to refine it. The present review focusses on the following key issues of perioperative coagulation monitoring: standardised bleeding history, routine coagulation testing, visco-elastic point-of-care coagulation testing, heparin monitoring, and platelet function testing.
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As the life expectancy of our Western population progressively increases, so does the prevalence of cardiovascular disease and thus the use of antithrombotic drugs. The use of central neuraxial anaesthesia techniques in patients treated with these drugs is a major clinical problem as the presence of an impaired coagulation has been found to be the most important risk factor contributing to the formation of a spinal haematoma. The growing number of case reports of spinal haematoma has led many national societies of anaesthetists to come up with guidelines. This article presents an overview of current guidelines on the use of regional anaesthetic techniques in patients treated with various anticoagulants and also describes a possible strategy to deal with new antithrombotic drugs that have recently been introduced in some countries or will be shortly in others.
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Interruption or maintenance of anti-platelet agents (APAs) during surgical or invasive procedures is associated with an increase in cardiovascular or haemorrhagic complications, respectively. The pharmacology and indications of aspirin, clopidogrel and prasugrel are summarised. The utility and risks of interruption, the optimal delay between stent implantation and surgery, the appropriate window of preoperative interruption, the potential usefulness of bridging, the safest delay between the end of surgery and resumption of APA are detailed in this review. Some non-evidence-based suggestions are given to help the physicians in their daily clinical practice.
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Best Pract Res Clin Anaesthesiol · Mar 2010
ReviewPerioperative coagulation management--fresh frozen plasma.
Clinical studies support the use of perioperative fresh frozen plasma (FFP) in patients who are actively bleeding with multiple coagulation factor deficiencies and for the prevention of dilutional coagulopathy in patients with major trauma and/or massive haemorrhage. In these settings, current FFP dosing recommendations may be inadequate. However, a substantial proportion of FFP is transfused in non-bleeding patients with mild elevations in coagulation screening tests. ⋯ FP24 and thawed plasma are alternatives to FFP with similar indications for administration. Both provide an opportunity for increasing the safe plasma donor pool. Although prothrombin complex concentrates and factor VIIa may be used as alternatives to FFP in a variety of specific clinical contexts, additional study is needed.
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Perioperative coagulopathy impacts on patient outcome by influencing final blood loss and transfusion requirements. The recognition of pre-existing disturbances and the basic understanding of the principles of and dynamic changes of haemostasis during surgery are pre-conditions for safe patient management. The newly developed cellular model of coagulation facilitates the understanding of coagulation, thereby underscoring the importance of the tissue factor-bearing cell and the activated platelet. ⋯ Recent data from studies using viscoelastic coagulation studies confirm the central role of fibrinogen in stable clot formation and provide essential knowledge about its changes during blood loss and fluid administration. Besides early decrease in clot firmness during mild-to-moderate dilution, profound dilution results in a critical decrease in thrombin generation as well as a reduction in numbers and function of platelets. Although our knowledge of perioperative coagulopathy has dramatically increased over the past few years, several questions such as critical thresholds for fibrinogen, platelets, impact of FXIII and TAFI remain unanswered and need to be investigated further.