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"apellidos" => "Jorques" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Complejo Hospitalario Universitario Granada, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Universitario Cruces, Bilbao, Vizcaya, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Anestesiología, Complejo Hospitalario Universitario Juan Canalejo, A Coruña, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Neurocirugía, Complejo Hospitalario Universitario Granada, Granada, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Guía de práctica clínica sobre tromboprofilaxis y manejo de los fármacos anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y neurocríticos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Venous thromboembolism (VTE), in the form of deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the leading causes of morbidity and mortality in hospitalised patients that can be prevented with appropriate prophylactic measures. PE, specifically, is the third leading cause of death in trauma patients who survive beyond the first 24<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">1</span></a> Despite improvements in thromboprophylaxis strategies following the development of guidelines and the introduction of automated electronic warning systems, many hospitalised patients at risk of VTE do not receive adequate treatment<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">2,3</span></a> and their management varies considerably.<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">4</span></a> Moreover, many physicians consider the risk of bleeding associated with pharmacological thromboprophylaxis to be more serious than the risk of VTE.<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">5,6</span></a> This is particularly evident in neurosurgery, where incidence of VTE is high, but the benefits of thromboprophylaxis must be weighed up against the consequences of bleeding, which are more serious compared to other types of surgery.<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">7,8</span></a> The optimal thromboprophylaxis strategy in neurosurgery patients remains unclear due to a paucity of clinical evidence, a situation that has led to a variety of strategies.<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">9,10</span></a> Similarly, there is insufficient clinical evidence on the management of neurosurgical patients receiving anticoagulants or antiplatelet therapy who are at high risk for thrombosis due to mechanical heart valves, atrial fibrillation (AF) with comorbidities, history of DVT, thrombophilia, or coronary artery stents.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In 2013, the Neuroscience Committee of the Spanish Society of Anaesthesiology, Intensive Care and Pain Therapy (SEDAR) conducted a survey of the anaesthesiology departments of all Spanish hospitals offering neurosurgery services. The results showed that only 27% have developed a written protocol for the perioperative management of anticoagulation/antiplatelet therapy and/or DVT prophylaxis in neurosurgical and/or neurocritical patients.<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This same committee subsequently drew up the following recommendations for thromboprophylaxis and anticoagulant and antiplatelet therapy in neurosurgical and/or neurocritical patients. For this purpose, the group undertook a systematic search of the most important bibliographic databases (Pubmed, Excerpta Médica, Embase, SciELO, Cochrane) to find articles published between 1972 and 2013 using the following keywords: deep vein thrombosis, neurosurgery, thromboembolism, thromboprophylaxis, mechanical prophylaxis, craniotomy, spinal surgery, antithrombotic drugs, bridging therapy, postoperative haemorrhage, head injury, new anticoagulants. Following this, the level of evidence of the main recommendations made in each study was graded according to the quality and strength criteria of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE)<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">12,13</span></a> system (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>). The level of evidence in some studies is low due to the difficult involved in performing randomised clinical trials in patients undergoing high bleed-risk surgery. The resulting clinical guidelines have been divided into 3 sections: thromboprophylaxis, antiplatelet therapy and anticoagulation therapy.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Thromboprophylaxis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Patients undergoing craniotomy have a moderate to high risk of DVT and PE, which is related with their underlying pathology, the type of surgical procedure performed, and the patient's health status. Incidence of clinically silent DVT in neurosurgical patients can be as high as 50% when diagnosed by lower limb Doppler ultrasound, and up to 31% of these patients are at risk of developing symptomatic DVT.<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">8,14,15</span></a> Therefore, these patients can be considered at high risk of developing DVT and PE during the postoperative period, particularly if they have undergone craniotomy for neoplasm.<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">16,17</span></a> In patients undergoing craniotomy for non-tumour-related pathologies, the risk is moderate.<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">8,17</span></a> Patients undergoing spinal surgery also have risk factors derived from the procedure itself, such as prone position with flexion of the hips and knees, or manipulation of the spine.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Indication for thromboprophylaxis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Two types of risk factors were evaluated to determine the indication for VTE prophylaxis:</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patient-related risk factors</span><p id="par0030" class="elsevierStylePara elsevierViewall">The presence of 1 or more risk factors for DVT,<a class="elsevierStyleCrossRefs" href="#bib0660"><span class="elsevierStyleSup">18–21</span></a> see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>, is an indication for thromboprophylaxis, and can determine the therapeutic approach, irrespective of the type of surgery performed (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). Risk factors should be noted in the patient's clinical history and preoperative report. Patients with modifiable risk factors, such as smoking, obesity or hormone (oestrogen) replacement therapy should ideally have these treated, provided their primary diagnosis allows surgery to be delayed until these factors have been corrected.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Surgery-related risk factors</span><p id="par0035" class="elsevierStylePara elsevierViewall">Surgery in itself can constitute a risk factor. Craniotomy in particular is an indication for thromboprophylaxis. In the case of spinal surgery, a recent systematic review of 25 studies has shown the global incidence of DVT to be 2.1%.<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">22</span></a> Furthermore, the 8th edition of the Clinical Practice Guidelines published by the American College of Chest Physicians in 2008 no longer recommends thromboprophylaxis in spinal surgery patients with no risk factors. The only recommended strategy is early, regular deambulation.<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">23</span></a> However, in the 9th edition published in 2012, recommendations for patients undergoing spinal surgery include mechanical prophylaxis over no prophylaxis, irrespective of the presence of risk factors (Grade 2C), unfractionated heparin (Grade 2C), or low-molecular-weight heparin (LMWH) (Grade 2C), based on evidence that the risk of major bleeding after spinal surgery with thromboprophylaxis is <0.5%.<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">24</span></a> For spinal surgery patients with a high risk of DVT (including malignant disease or surgery with a combined anterior–posterior approach), the guidelines suggest adding pharmacologic prophylaxis to mechanical prophylaxis once adequate haemostasis is established and the risk of bleeding decreases (Grade 2C).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Recommendations for cervical spinal surgery with an anterior approach. Although the incidence of cervical haematoma is relatively low (0.2–1.9%),<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">25</span></a> it is a dangerous complication that can compromise the airway. A retrospective study of 2375 patients undergoing anterior cervical spine surgery reported a similar incidence of haematoma (0.7%).<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">26</span></a> The risk factors found were primarily associated with the complexity of the surgical procedure (surgery across various levels, idiopathic hyperostosis or ossified posterior longitudinal ligament, and prolonged surgery). A higher incidence of cervical haematoma was also observed with administration of anticoagulant doses of heparin.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Types of thromboprophylaxis</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Mechanical thromboprophylaxis</span><p id="par0045" class="elsevierStylePara elsevierViewall">This is the safest type of thromboprophylaxis in high-bleed-risk surgery.<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">16,17,27,28</span></a> There are 2 main types of mechanical prophylaxis: graduated compression stockings (GCS) or intermittent pneumatic compression (IPC).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Mechanical prophylaxis with GCS is the recommended first line therapy in the guidelines published by the National Institute for Health and Clinical Excellence,<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">29</span></a> and is also the most widely used prophylaxis in Spanish hospitals (83%). Nevertheless, its effectiveness has not been proved conclusively, mainly due to the poor quality of the studies available, many of which are not double blind and are hard to interpret because the wide range of compression stockings results in the formation of heterogeneous patient groups.<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">30</span></a> A recent multicentre randomised clinical trial in more than 2500 stroke patients did not find GCS effective in preventing DVT.<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">31</span></a> Either way, the definitive benefit of prophylaxis with GCS remains unclear, and further trials are needed to clarify contradictory findings and show whether GCS alone is effective in preventing DVT in patients with a high bleeding risk.<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">32</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Fortunately, findings from studies on IPC are more consistent. IPC prevents venous thrombosis both by increasing venous blood flow in the lower limbs, and by stimulating endogenous fibrinolysis by reducing plasminogen activator inhibitor-1 levels, which in turn increases tissue plasminogen activator activity.<a class="elsevierStyleCrossRefs" href="#bib0735"><span class="elsevierStyleSup">33–35</span></a> IPC also reduces platelet activity.<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">36</span></a> Some IPC devices offer rapid inflation to achieve high peak blood flow velocities in the veins, but have less effect on fibrinolysis.<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">37</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In a systematic review of 22 clinical trials on IPC in a total of 2779 patients, IPC reduced the risk of DVT by 64%,<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">38</span></a> while a recent multicentre clinical trial has shown this method to be effective in medical patients.<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">39</span></a> A meta-analysis of 70 clinical trials with a total of 16,164 patients showed that IPC is significantly more effective in reducing DVT than no IPC prophylaxis (7.3% vs 16.7%, relative risk 0.43). In neurosurgery, meanwhile, a randomised clinical trial showed a significant reduction in the incidence of DVT in this patient population following IPC prophylaxis (relative risk 0.21).<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">40</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Although there is scant evidence in the literature, the data available suggest that IPC should ideally be started immediately before surgery. Treatment should continue until the patient is fully ambulatory,<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">35</span></a> and the device should be used for 18<span class="elsevierStyleHsp" style=""></span>h each day.<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">41</span></a> IPC is a useful bridging measure until pharmacological prophylaxis can be started in patients at high risk of thrombosis.<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">28</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Some aspects of IPC therapy, however, remain unclear, such as whether full leg, half leg and foot devices are comparable.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pharmacological thromboprophylaxis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Unlike mechanical thromboprophylaxis, pharmacological anti-DVT treatment with heparin, particularly LMWH, has been more extensively studied. The American College of Chest Physicians recommends LMWH in patients at high risk for DVT, such as those undergoing craniotomy for malignant disease (the largest craniotomy subgroup).<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">24</span></a> With regard to risk for bleeding, a systematic review and meta-analysis of pharmacological thromboprophylaxis in craniotomy patients included 6 randomised clinical trials evaluating the effect of heparin (both unfractionated and low molecular weight) vs controls in a total of 1170 patients. In the heparin prophylaxis group, both silent and symptomatic DVT was significantly reduced, with a relative risk of 0.58 (0.45–0.75 with a 95% confidence interval) and an absolute risk reduction of 9.1% for DVT. Nevertheless, incidence of intracranial haemorrhage was higher, albeit not significantly, in the heparin group, with a relative risk of intracranial haemorrhage of 1.48 (0.63–3.44 with a 95% confidence interval) and an absolute risk increase of 0.7% for intracranial haemorrhage.<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">With regard to the recommended regimen, administration of LMWH 24<span class="elsevierStyleHsp" style=""></span>h after surgery is considered safe<a class="elsevierStyleCrossRefs" href="#bib0620"><span class="elsevierStyleSup">10,42</span></a>; however, bearing in mind that the critical period for development of postoperative intracranial haematoma is 2 days after craniotomy,<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">17</span></a> it would be reasonable to respect this safety window.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Thromboprophylaxis regimen</span><p id="par0085" class="elsevierStylePara elsevierViewall">In spinal surgery patients without risk factors, or with 1–2 risk factors, LMWH is indicated 12<span class="elsevierStyleHsp" style=""></span>h after surgery at a prophylactic dose (Grade 2C), or optimal perioperative intermittent pneumatic compression therapy should be administered (Grade 2C). In patients with 3 or more risk factors, the combination of mechanical prophylaxis with IPC plus LMWH 12<span class="elsevierStyleHsp" style=""></span>h after surgery (Grade 2C) is indicated. In this case, GCS can be used instead of IPC (Grade 2D). In patients undergoing complex anterior spinal surgery, optimal use of IPC is recommended over pharmacological thromboprophylaxis (Grade 2C).</p><p id="par0090" class="elsevierStylePara elsevierViewall">In craniotomy, optimal use of IPC is always recommended (Grade 2B), irrespective of the presence of risk factors. However, in patients with more than 3 risk factors, mechanical prophylaxis with IPC should be combined with LMWH 48<span class="elsevierStyleHsp" style=""></span>h after surgery, once bleeding has stopped and there is no clinical and/or radiological evidence of intracranial bleeding (Grade 2C). In the latter case, GCS can be used instead of IPC (Grade 2D). A platelet count should also be performed twice a week, together with a coagulation test. Measures should be taken to prevent hypertension.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Antiplatelet treatment</span><p id="par0095" class="elsevierStylePara elsevierViewall">Nearly 10 million patients suffer major perioperative cardiovascular complications each year, such as myocardial infarction, stroke, and death.<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">43</span></a> Antiplatelet agents (APA) (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>) play a key role in perioperative management strategies, both as treatment and secondary prophylaxis in patients with coronary, cerebral or peripheral vein thrombosis<a class="elsevierStyleCrossRefs" href="#bib0790"><span class="elsevierStyleSup">44–49</span></a> and also as primary prophylaxis against thrombotic event in patients with risk factors.<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">49–51</span></a></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">In 2011, the SEDAR published its clinical practice guidelines on the preoperative management of platelet aggregation antagonists in non-cardiac surgery.<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">47</span></a> The guidelines include recommendations for the perioperative management of APAs in non-cardiac surgery, including patients at high risk of bleeding, in whom perioperative haemorrhage can be life threatening or affect the outcome of procedures such as craniotomy, spinal canal surgery or interventions in the posterior chamber of the eye. The role of perioperative APAs in non-cardiac surgery is still widely debated, while their management in neurosurgery, particularly craniotomy, is even less clear.<a class="elsevierStyleCrossRefs" href="#bib0830"><span class="elsevierStyleSup">52–54</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Elective surgery</span><p id="par0105" class="elsevierStylePara elsevierViewall">According to various clinical practice guidelines, the general recommendation in most non-cardiac interventions in patients at high to moderate risk of thrombosis receiving APA monotherapy, such as aspirin or clopidogrel is to continue with anti-platelet therapy, irrespective of whether the surgery is elective or urgent (Grade 2A).<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">55–57</span></a> If APAs are used as primary prophylaxis, they should generally be discontinued, and clopidogrel or high-dose aspirin should be replaced with aspirin at a dose of 100<span class="elsevierStyleHsp" style=""></span>mg from 2 to 5 days before surgery.<a class="elsevierStyleCrossRefs" href="#bib0805"><span class="elsevierStyleSup">47,58</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The exception to the above is craniotomy, in which guidelines recommend, in general, the suspension of all antiplatelet therapy prior to elective craniotomy, as the risk of bleeding outweighs the risk of thrombosis in these patients.<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">16,59,60</span></a> However, no randomised clinical trials have shown the best strategy for interrupting APAs prior to surgery.<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">58</span></a> More importantly, it is important to bear in mind the potentially negative consequences of interrupting antiplatelet therapy. Some studies have reported that interruption of antiplatelet therapy with aspirin in coronary patients increases the risk of cardiovascular complications threefold, above all between 7 and 14 days after suspension<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">61–63</span></a>; the same is true of patients with cerebrovascular and peripheral artery disease.<a class="elsevierStyleCrossRefs" href="#bib0890"><span class="elsevierStyleSup">64,65</span></a> Copidogrel has been reported to increase incidence of cardiovascular complications and mortality 3 months after interruption in patients with acute coronary syndrome.<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">66</span></a> Other studies, however, are contradictory; a recent clinical trial in non-cardiac surgery patients (undergoing orthopaedic, abdominal and urological surgery) found no differences in the incidence of thrombotic events and haemorrhage between a group receiving aspirin and another receiving placebo.<a class="elsevierStyleCrossRef" href="#bib0905"><span class="elsevierStyleSup">67</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Moreover, some hospitals perform extra–intra cranial bypass without interrupting aspirin in order to improve anastomosis,<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">17</span></a> while in others, craniotomy, particularly in patients with a coronary artery stent, is performed with aspirin at a dose of 100<span class="elsevierStyleHsp" style=""></span>mg, depending on the patient's risk factors.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Similarly, greater consensus and more specific recommendations for spinal surgery patients are needed. In this regard, some scientific societies, such as the Cardiac Society of Australia, draw a parallel with intracranial surgery and recommend suspending antiplatelet therapy in spinal surgery due to the risk of bleeding.<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">60</span></a> The results of the SEDAR survey on the management of antiplatelet therapy in elective spinal and/or spinal cord surgery largely coincide with recommendations for craniotomy, which supports the adoption of a similar strategy in these interventions.<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">11</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Patients with coronary artery stents are most probably the most complex of all neurosurgical cases. These patients have a high risk of thrombosis, particularly within the first year of stent implantation. The risk of patients with coronary stents developing serious cardiovascular complications after non-cardiac surgery is between 8% and 10%. Approximately 900,000 patients receive coronary stents each year in the USA,<a class="elsevierStyleCrossRef" href="#bib0910"><span class="elsevierStyleSup">68</span></a> and 4–5% (40,000) will undergo surgery within 1 year of receiving the stent, and around 11% (99,000 patients) within 2 years.<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">69</span></a> Within this group, a considerable number will undergo neurosurgery. The lack of consensus on the management of these patients is reflected in the results of a recent survey conducted by the SEDAR, in which 47% of hospitals perform intracranial surgery in patients with coronary stents while on 100<span class="elsevierStyleHsp" style=""></span>mg/day oral aspirin as antiplatelet monotherapy, while 55% perform the same intervention using combination antiplatelet therapy.<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">11</span></a> None perform craniotomies while patients are receiving clopidogrel.</p><p id="par0130" class="elsevierStylePara elsevierViewall">A recent systematic review of clinical practice guidelines on the management of APAs in patients with coronary artery stents scheduled for non-cardiac surgery has drawn attention to the weak scientific evidence on the management of these patients.<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">54</span></a> Following stent placement, guidelines recommend that patients receive combination antiplatelet therapy,<a class="elsevierStyleCrossRefs" href="#bib0920"><span class="elsevierStyleSup">70,71</span></a> usually with aspirin and clopidogrel, for between 6 weeks and 12 months. However, there is no clear strategy outlining the management of these patients in non-cardiac surgery, particularly neurosurgery, and a number of questions remain: when should patients with coronary stents undergo elective surgery? Which APA should be interrupted? How long before surgery should APAs be interrupted, and when should administration resume? Is there a suitable bridging therapy, and if so, is it required?</p><p id="par0135" class="elsevierStylePara elsevierViewall">A recent study in patients with coronary stents set out to clarify these issues and to modify certain recommendations in future clinical practice guidelines by showing that non-scheduled hospitalisation is the primary factor determining onset of serious adverse cardiac events, followed by recent myocardial infarction, heart failure, or a high revised cardiac risk index score.<a class="elsevierStyleCrossRef" href="#bib0930"><span class="elsevierStyleSup">72</span></a> However, the type of stent (drug-eluting or conventional) or the delay before surgery are not associated with an increase in adverse cardiac events, and most importantly for neurosurgical patients, the authors found no association between interruption of APA therapy and onset of serious cardiac events. Moreover, incidence of adverse cardiac event was higher among patients receiving combination antiplatelet therapy, not only due to a greater cardiac risk, but also because perioperative bleeding was the primary cause of adverse outcomes.<a class="elsevierStyleCrossRef" href="#bib0930"><span class="elsevierStyleSup">72</span></a> This supports the strategy of interrupting APAs as primary and secondary prophylaxis in candidates for intracranial and/or spinal surgery, including patients with coronary stents, and strongly suggests that it should be considered a specific recommendation and not just an exception to the general rule of cardiac surgery.</p><p id="par0140" class="elsevierStylePara elsevierViewall">According to the SEDAR survey, if antiplatelet therapy is interrupted before craniotomy in patients at high risk of thrombosis, many (46%) hospitals resume APA therapy 24<span class="elsevierStyleHsp" style=""></span>h after surgery. The recently documented absence of an association between interruption of antiplatelet therapy and onset of serious cardiac events will probably increase the safety window between the end of surgery and resumption of APA therapy. This is important if we consider that the critical period for the onset of postoperative cerebral haematoma is 2 days, and the most common risk factor associated with this is antiplatelet therapy.<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">17</span></a> It is important to remember that the antiplatelet action of aspirin peaks within minutes of administration, while clopidogrel, at a maintenance dose, will need between 5 and 10 days.<a class="elsevierStyleCrossRef" href="#bib0935"><span class="elsevierStyleSup">73</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Bridging therapy has been used in patients at high risk of thrombosis in whom antiplatelet therapy needs to be temporarily suspended due to the risk of bleeding, or when surgery must be performed shortly after stent placement and clopidogrel needs to be suspended.<a class="elsevierStyleCrossRef" href="#bib0940"><span class="elsevierStyleSup">74</span></a> This basically involves administration of a shorter-acting antiplatelet agent than those usually used (aspirin and clopidogrel). Nonsteroidal anti-inflammatory drugs or glycoprotein IIb/IIIa inhibitors<a class="elsevierStyleCrossRefs" href="#bib0945"><span class="elsevierStyleSup">75–77</span></a> have been used as a bridge in these cases, although there is little clinical evidence to support this strategy. Very few studies on the use of glycoprotein IIb/IIIa inhibitors as bridging therapy have been published, although tirifiban has shown promising results in patients undergoing non-cardiac surgery shortly after coronary stent placement in whom clopidogrel has been interrupted, with no evidence of major bleeding complications.<a class="elsevierStyleCrossRefs" href="#bib0960"><span class="elsevierStyleSup">78,79</span></a> These findings, however, cannot be extrapolated to patients undergoing intracranial surgery as these cases were excluded from these studies due to the risk of bleeding.</p><p id="par0150" class="elsevierStylePara elsevierViewall">New-generation APAs, prasugrel and ticagrelor, are more powerful, faster acting, and with a less variable effect than clopidogrel. There are no studies on the preoperative management of these drugs in non-cardiac surgery. According to the literature, however, management of prasugrel and ticagrelor should be based on the pharmokinetic and pharmodynamic properties of each drug.<a class="elsevierStyleCrossRefs" href="#bib0970"><span class="elsevierStyleSup">80,81</span></a> In the case of ticagrelor (a reversible P2Y<span class="elsevierStyleInf">12</span> receptor antagonist), management should be similar to clopidogrel. Prasugrel, however, being an irreversible P2Y<span class="elsevierStyleInf">12</span> receptor antagonist, should be withdrawn for no more than 7 days.<a class="elsevierStyleCrossRef" href="#bib0980"><span class="elsevierStyleSup">82</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Emergency surgery</span><p id="par0155" class="elsevierStylePara elsevierViewall">A retrospective study in 626 patients with traumatic brain injury has shown that a platelet count <175<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/l is associated with greater intracranial haemorrhage progression, while <100<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/l is an independent risk factor for mortality (ninefold risk of death).<a class="elsevierStyleCrossRef" href="#bib0985"><span class="elsevierStyleSup">83</span></a> Although studies have evaluated the benefit of preoperative platelet transfusion, there is as yet no evidence to show that this strategy affects clinical outcomes in anticoagulated patients with traumatic brain injury, or ameliorates haematoma enlargement.<a class="elsevierStyleCrossRef" href="#bib0990"><span class="elsevierStyleSup">84</span></a></p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Antiplatelet management in neurosurgery</span><p id="par0160" class="elsevierStylePara elsevierViewall">Consensus guidelines recommend interrupting APA therapy (aspirin or clopidogrel) 7 days prior to surgery in patients scheduled for intracranial or spinal surgery that have previously received aspirin as primary prevention. In patients receiving either aspirin or clopidogrel as secondary prevention, consensus guidelines recommend interrupting aspiring 2–5 days and clopidogrel 3–5 days before surgery. In patients on dual antiplatelet therapy with aspirin and clopidogrel due to recent implantation of a coronary stent, both should be interrupted 3–5 days before surgery. In these patients, bridging therapy with nonsteroidal anti-inflammatory drugs or glycoprotein IIb/IIIa inhibitors is not recommended. Depending on the urgency of the intervention (for example, malignant disease, chronic pain, etc.), surgery can be delayed in order to reduce cardiovascular risk factors, such as recent myocardial infarction, heart failure, etc. (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>).</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Guidelines recommend resuming APA therapy 48<span class="elsevierStyleHsp" style=""></span>h after surgery, provided there are no bleeding complications.</p><p id="par0170" class="elsevierStylePara elsevierViewall">In the event of emergency intracranial or spinal surgery in patients on APA therapy, experts agree in recommending platelet transfusion if bleeding occurs, not as prophylaxis, although there is no evidence that this reverses the clopidogrel effect.<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">57</span></a> Administration of antifibrinolytics, such a tranexamic acid, desmopressin or factor VIIa (FVIIa) can also be considered.</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Anticoagulant therapy</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Oral anticoagulants</span><p id="par0175" class="elsevierStylePara elsevierViewall">For many years, vitamin K antagonists have been the only oral anticoagulant drugs available for clinical use for the primary and secondary prevention of venous and arterial thromboembolic events (<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>). Today, millions of patients receive these drugs.<a class="elsevierStyleCrossRef" href="#bib0995"><span class="elsevierStyleSup">85</span></a></p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Elective surgery</span><p id="par0180" class="elsevierStylePara elsevierViewall">It is important to understand the pharmacology of OACs used in the management of neurosurgery patients. The half-life of acenocoumarol, the most widely used OAC in Spain, is 8–11<span class="elsevierStyleHsp" style=""></span>h, although its antivitamin K action persists for 48–72<span class="elsevierStyleHsp" style=""></span>h. For this reason, it should be suspended approximately 72<span class="elsevierStyleHsp" style=""></span>h before surgery. Warfarin, meanwhile, should be suspended 5 days before surgery.<a class="elsevierStyleCrossRef" href="#bib1000"><span class="elsevierStyleSup">86</span></a> Studies have shown that INR was >1.5, 1 day before surgery in 7% of patients following preoperative suspension of OACs.<a class="elsevierStyleCrossRefs" href="#bib1005"><span class="elsevierStyleSup">87,88</span></a> Performing blood tests 1 day prior to surgery will identify patients with a high INR level that require oral vitamin K therapy (1–2.5<span class="elsevierStyleHsp" style=""></span>mg) to avoid delaying surgery. As an emergency measure, vitamin K at a dose of 1–10<span class="elsevierStyleHsp" style=""></span>mg (depending on the INR level) can be administered intravenously. INR will start to fall after 2<span class="elsevierStyleHsp" style=""></span>h, and can potentially normalise within 24<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRefs" href="#bib1015"><span class="elsevierStyleSup">89,90</span></a> Further doses of vitamin K may be required after 6–8<span class="elsevierStyleHsp" style=""></span>h, according to INR levels.</p><p id="par0185" class="elsevierStylePara elsevierViewall">As in other types of surgery, in neurosurgery patients previously anticoagulated due to a high risk of thromboembolism (for example, history of thrombophilia, AF with implantation of mechanical heart valve, implantation of mechanical heart valve less than 3 months previously, etc.), OACs should be replaced by LMWH as bridging therapy until 1 day prior to surgery. This is considered safe in several different types of surgery<a class="elsevierStyleCrossRefs" href="#bib1025"><span class="elsevierStyleSup">91–93</span></a> except for neurosurgery, where there is insufficient evidence to define a gold standard bridging regimen. This is due to the exclusion of this patient population in most studies, and to significant variations in patient population, study design, and perioperative anticoagulation regimens. Despite these limitations, some authors suggest that administration of a prophylactic dose of LMWH between 12 and 24<span class="elsevierStyleHsp" style=""></span>h prior to surgery is safe. This dose can then be gradually stepped up to therapeutic levels over a period of 2 weeks post-surgery.<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">42,94</span></a> The ideal time to administer the last bridging dose of LMWH before intracranial and/or spinal surgery is also unclear, However, reports of a higher incidence of haemorrhage in patients receiving LMWH at therapeutic doses<a class="elsevierStyleCrossRef" href="#bib1025"><span class="elsevierStyleSup">91</span></a> suggest that it is unsafe to administer this therapy shortly before intracranial and spinal surgery.<a class="elsevierStyleCrossRef" href="#bib1045"><span class="elsevierStyleSup">95</span></a> A recent SEDAR survey has shown that 51% of hospitals administer the last therapeutic dose of LMWH 24<span class="elsevierStyleHsp" style=""></span>h before surgery in patients previously receiving dicoumarins who are switched to preoperative LMWH before craniotomy.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Emergency surgery</span><p id="par0190" class="elsevierStylePara elsevierViewall">In patients presenting with intracranial bleeding secondary to trauma while on anticoagulation therapy, risk of mortality is greater that in those with no previous treatment.<a class="elsevierStyleCrossRefs" href="#bib1045"><span class="elsevierStyleSup">95–98</span></a> Since post-traumatic intracranial haemorrhage tends to progress, previous anticoagulation therapy should be immediately reversed, taking appropriate measures to normalise haemostasis and improve the patient's prognosis.<a class="elsevierStyleCrossRef" href="#bib1065"><span class="elsevierStyleSup">99</span></a> According to the SEDAR survey on anticoagulated patients, most (80%) hospitals use prothrombin complex concentrate (PCC) or, to a lesser extent fresh frozen plasma (FFP) to reverse anticoagulants. Although FFP is described in the literature as the most widely used OAC reversal strategy,<a class="elsevierStyleCrossRefs" href="#bib0995"><span class="elsevierStyleSup">85,100</span></a> PCC is probably more effective than FFP in normalising INR.<a class="elsevierStyleCrossRef" href="#bib0995"><span class="elsevierStyleSup">85</span></a> The advantages of PCC in the context of urgent intracranial surgery are probably greater efficacy, less volume and faster administration, and no need for cross matching.</p><p id="par0195" class="elsevierStylePara elsevierViewall">FVIIa has been used in patients with life-threatening bleeding refractory to treatment.<a class="elsevierStyleCrossRef" href="#bib1010"><span class="elsevierStyleSup">88</span></a> There is little evidence to support the use of FVIIa combined with OACs to treat haemorrhage, and it is only recommended as a last resort in life-threatening situations.<a class="elsevierStyleCrossRef" href="#bib1075"><span class="elsevierStyleSup">101</span></a></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">New oral anticoagulants</span><p id="par0200" class="elsevierStylePara elsevierViewall">Novel oral anticoagulants (NOAC) have recently been introduced into clinical practice, namely, dabigatran, a direct thrombin inhibitor, and rivaroxaban and apixaban, which are direct factor Xa inhibitors. Evidence suggests that these preparations are more effective and safer than traditional OACs<a class="elsevierStyleCrossRefs" href="#bib1080"><span class="elsevierStyleSup">102–106</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>). NOACs have a faster onset of action, shorter half-life, few drug interactions, and predictable pharmacokinetics that does not require monitoring. However, no drugs have so far been shown to be effective in reversing the action of these NOACs and reactivating haemostasis mechanisms<a class="elsevierStyleCrossRefs" href="#bib1105"><span class="elsevierStyleSup">107,108</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a>).</p><elsevierMultimedia ident="tbl0040"></elsevierMultimedia><elsevierMultimedia ident="tbl0045"></elsevierMultimedia><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Elective surgery</span><p id="par0205" class="elsevierStylePara elsevierViewall">Thrombin time, or failing that, activated partial thromboplastin time (aPPT), despite their limitations, can provide qualitative data to evaluate the anticoagulant effect of dabigatran. For rivaroxaban, prothrombin time is used, and in the case of apixaban, the anti-factor Xa activity test is performed.<a class="elsevierStyleCrossRef" href="#bib1110"><span class="elsevierStyleSup">108</span></a> Normal findings in these tests indicate low NOAC plasma levels and normal haemostasis<a class="elsevierStyleCrossRef" href="#bib1115"><span class="elsevierStyleSup">109</span></a>; however, the results of these tests should always be interpreted relative to the last NOAC dose administered. Until further evidence on the clinical usefulness of these tests becomes available, a safety margin between the last NOAC dose and the start of surgery should be observed, bearing in mind the bleeding risk associated with the procedure, the pharmacokinetics of NOACs, and kidney function (for example, surgery should be delayed ≥1 half-life after the last dose of dabigatran, or until aPTT is normal or near normal).<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">45</span></a> While interventions in patients with standard bleeding risk and normal kidney function should be delayed 24<span class="elsevierStyleHsp" style=""></span>h,<a class="elsevierStyleCrossRef" href="#bib1120"><span class="elsevierStyleSup">110</span></a> this should be extended to between 2 and 6 days in high bleed risk cases.<a class="elsevierStyleCrossRefs" href="#bib1115"><span class="elsevierStyleSup">109–112</span></a> This strategy has been shown to be as safe as traditional OACs in terms of perioperative bleeding and thrombotic events. It restores normal haemostasis more rapidly, thus obviating the need for bridging therapy.<a class="elsevierStyleCrossRef" href="#bib1130"><span class="elsevierStyleSup">112</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Emergency surgery</span><p id="par0210" class="elsevierStylePara elsevierViewall">In a study in healthy volunteers, administration of high-dose PCC (50<span class="elsevierStyleHsp" style=""></span>U/kg) normalised prolongation of the prothrombin time induced by rivaroxaban, but did not neutralise the effect of dabigatran on aPTT.<a class="elsevierStyleCrossRef" href="#bib1135"><span class="elsevierStyleSup">113</span></a> Despite the paucity of clinical evidence available to date, it is reasonable to recommend PCC in patients undergoing emergency intracranial surgery while on NOACs, particularly rivaroxaban. However, there is no evidence to support the clinical benefit of transfusion of FFP or FVIIa to reverse the effects of NOACs. In the case of dabigatran, oral activated charcoal can be given shortly after intake, and this suspension can adsorb 99.9% of the drug.<a class="elsevierStyleCrossRef" href="#bib1125"><span class="elsevierStyleSup">111</span></a> Haemodialysis is an option in the event of active bleeding or impairment of kidney function.<a class="elsevierStyleCrossRef" href="#bib1140"><span class="elsevierStyleSup">114</span></a> Rivaroxaban and apixaban, being highly protein-bound, cannot be dialyzed. If bleeding occurs, other therapies such as desmopressin and antifibrinolytic agents such a tranexamic acid and epsilon-aminocaproic acid have been evaluated, although they have not been shown to be effective.<a class="elsevierStyleCrossRefs" href="#bib1110"><span class="elsevierStyleSup">108,109</span></a></p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Anticoagulant management in neurosurgery</span><p id="par0215" class="elsevierStylePara elsevierViewall">In neurosurgical patients previously anticoagulated due to a high risk of thromboembolism (for example, history of thrombophilia, AF with implantation of mechanical heart valve, implantation of mechanical heart valve less than 3 months previously, etc.) that have been switched to LMWH bridging therapy prior to craniotomy, the last therapeutic dose of LMWH should be administered 24<span class="elsevierStyleHsp" style=""></span>h prior to intracranial or spinal surgery (Grade 2C). LMWH at therapeutic doses should not be administered in the first week following craniotomy.</p><p id="par0220" class="elsevierStylePara elsevierViewall">In patients requiring emergency surgery, PCC, or alternatively FFP, should be administered to normalise INR (Grade 2C). FVIIa can be considered if bleeding does not respond to the foregoing measures (level of evidence D).</p><p id="par0225" class="elsevierStylePara elsevierViewall">In patients on NOACs, these should be interrupted 2–6 days before surgery, after evaluating the risk-benefit in each case. In patients requiring emergency surgery, high-dose PCCs should be administered. Other therapies, such as desmopressin and antifibrinolytic agent can also be considered.</p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:3 [ "identificador" => "sec0010" "titulo" => "Thromboprophylaxis" "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Indication for thromboprophylaxis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Patient-related risk factors" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Surgery-related risk factors" ] ] ] 1 => array:3 [ "identificador" => "sec0030" "titulo" => "Types of thromboprophylaxis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Mechanical thromboprophylaxis" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Pharmacological thromboprophylaxis" ] ] ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Thromboprophylaxis regimen" ] ] ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Antiplatelet treatment" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Elective surgery" ] 4 => array:3 [ "identificador" => "sec0060" "titulo" => "Emergency surgery" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Antiplatelet management in neurosurgery" ] ] ] 5 => array:3 [ "identificador" => "sec0070" "titulo" => "Anticoagulant therapy" "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0075" "titulo" => "Oral anticoagulants" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Elective surgery" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "Emergency surgery" ] ] ] 1 => array:3 [ "identificador" => "sec0090" "titulo" => "New oral anticoagulants" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Elective surgery" ] 1 => array:2 [ "identificador" => "sec0100" "titulo" => "Emergency surgery" ] ] ] 2 => array:2 [ "identificador" => "sec0105" "titulo" => "Anticoagulant management in neurosurgery" ] ] ] 6 => array:2 [ "identificador" => "sec0110" "titulo" => "Conflict of interests" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-01-13" "fechaAceptado" => "2016-01-18" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Please cite this article as: Vázquez-Alonso E, Iturri Clavero F, Valencia Sola L, Fábregas N, Ingelmo Ingelmo I, Valero R, et al. Guía de práctica clínica sobre tromboprofilaxis y manejo de los fármacos anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y neurocríticos. Rev Esp Anestesiol Reanim. 2016;63:406–418.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0035">This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page: <a class="elsevierStyleInterRef" id="intr0005" href="http://www.elsevier.es/redar">www.elsevier.es/redar</a>.</p>" ] ] "multimedia" => array:9 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">OR, odds ratio; RR, relative risk.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>: Castillo-Bustos et al.<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">12</span></a> and Oñate-Ocaña et al.<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">13</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Step 1<br>Initial grade of evidence \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Step 2<br>Decrease grade (1, −1, −2) if \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Step 3<br>Increase grade (0, +1, +2) if \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Quality of evidence \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">High</span><br><span class="elsevierStyleHsp" style=""></span>Grade 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Randomised clinical trial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limitations to study quality<br>Serious: −1<br>Very serious: −2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Strength of association<br>Strong: +1<br>RR/OR >2 or <0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A<br>High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Moderate</span><br><span class="elsevierStyleHsp" style=""></span>Grade 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Quasi-experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Inconsistent findings: −1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Very strong association: +2<br>RR/OR >5 or <0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B<br>Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Low</span><br><span class="elsevierStyleHsp" style=""></span>Grade 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Observational \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Differences in population, interventions or outcome variables: (−1, −2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Evidence of dose response gradient: +1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C<br>Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Very low</span><br><span class="elsevierStyleHsp" style=""></span>Grade 0–1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Imprecise data: −1<br>Possible bias: −1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Confounding factors would have reduced the effect: +1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D<br>Very low \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1123037.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Grading quality of evidence according to GRADE.</p>" ] ] 1 => array:9 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Castillo-Bustos et al.<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">12</span></a> and Oñate-Ocaña et al.<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">13</span></a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Requirements \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Implications \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Strong 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High evidence<br>Net benefit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recommendation should be followed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weak 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moderate or high evidence<br>Trade offs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The recommendation can be followed, but consider other factors before deciding \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Consensus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low, very low or no evidence, but with solid benefit harm criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recommendations have been made, but individual criteria should prevail \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1123041.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estimated grade of recommendation according to GRADE.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">BMI, body mass index; DVT, deep vein thrombosis; LL, lower limbs; PE, pulmonary embolism.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>40 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Congestive heart failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>60 years<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stroke \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">History of DVT or PE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Major LL trauma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Myeloproliferative disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thrombophilia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recent surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LL immobility or paresthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nephrotic syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obesity BMI<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vasculitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Family history of thrombophilia or DVT/PE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Inflammatory bowel disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Central venous catheter \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pregnancy (include postpartum period) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Atherosclerosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oestrogen therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgery<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Venous insufficiency or varicose veins \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1123040.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Age<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>60 contributes 2 risk factors.</p> <p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleItalic">Source</span>: Heit et al.,<a class="elsevierStyleCrossRefs" href="#bib0660"><span class="elsevierStyleSup">18,19</span></a> Anderson et al.<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">20</span></a> and Blann et al.<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">21</span></a></p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patient-related DVT risk factors.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">GCS, graduated compression stockings; IPC, intermittent pneumatic compression; LMWH, low molecular weight heparin.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><3 risk factors \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">≧3 risk factors \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spinal surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LMWH 12 after surgery or IPC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IPC<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>LMWH 12<span class="elsevierStyleHsp" style=""></span>h after surgery<br>GCS (alternative to IPC) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Craniotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IPC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IPC<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>LMWH 48<span class="elsevierStyleHsp" style=""></span>h after surgery<br>GCS (alternative to IPC) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1123034.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Thromboprophylaxis regimen.</p>" ] ] 4 => array:9 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Hall et al.<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">52</span></a> and Mohr et al.<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">53</span></a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="8" align="left" valign="middle">Enzyme inhibitors</td><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Cyclooxygenase inhibitors (COX-1)</td><td class="td" title="table-entry " align="left" valign="top">Acetylsalicylic acid \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Triflusal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nitro-aspirin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ditazol \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NSAID \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Phosphodiesterase inhibitors</td><td class="td" title="table-entry " align="left" valign="top">Dipiridamol \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cilostazol \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mopidamol \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="22" align="left" valign="middle">Receptor antagonists</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Irreversible ADP (P2Y<span class="elsevierStyleInf">12</span>, P2Y<span class="elsevierStyleInf">12</span>) receptor antagonists (thienopyridines)</td><td class="td" title="table-entry " align="left" valign="top">Ticlopidine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clopidogrel \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prasugrel \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Reversible ADP (P2Y12, P2Y<span class="elsevierStyleInf">12</span>) receptor antagonists</td><td class="td" title="table-entry " align="left" valign="top">Cangrelor \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ticagrelor \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Elinogrel \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="7" align="left" valign="top">Glycoprotein IIb/IIIa inhibitors</td><td class="td" title="table-entry " align="left" valign="top">Eptifibatide (Integrilin<span class="elsevierStyleSup">®</span>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tirofiban (Aggrastat<span class="elsevierStyleSup">®</span>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abciximab (Reopro<span class="elsevierStyleSup">®</span>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Xemilofiban \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sibrafiban \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Orfiban \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lotrafiban \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">PAR receptor antagonists (PAR1, PAR4)</td><td class="td" title="table-entry " align="left" valign="top">Terutroban \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">E5555 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCH-530348 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pepducins \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aprotinin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="6" align="left" valign="top">Thromboxane receptor antagonists (TXA<span class="elsevierStyleInf">2</span>R)</td><td class="td" title="table-entry " align="left" valign="top">S188886 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Picotamide \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ridogrel \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="middle">Adenylyl cyclase stimulators</td><td class="td" title="table-entry " align="left" valign="top">Epoprostenol \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Iloprost \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1123035.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Pharmacological classification of antiplatelet agents.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aspirin \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clopidogrel<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aspirin<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>clopidogrel \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Primary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interruption 7 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interruption 7 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Secondary prevention<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interruption 2–5 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interruption 3–5 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interruption 3–5 days<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Emergency surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="3" align="left" valign="top">Platelet transfusion for haemorrhage<br>Tranexamic acid<br>Desmopressin (alternative)<br>FVIIa (alternative)</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1123036.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Including patients with coronary stents.</p>" ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">No bridging therapy recommended, the type of intervention may justify delaying surgery.</p>" ] 2 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Management of ticagrelor is similar to clopidogrel. Prasugrel should be interrupted for 7 days.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Antiplatelet drug management in intracranial and spinal surgery.</p>" ] ] 6 => array:9 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Ageno et al.<a class="elsevierStyleCrossRef" href="#bib0995"><span class="elsevierStyleSup">85</span></a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at7" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Half-life \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Onset of effect \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Therapeutic action \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Offset of action \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acenocumarol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12–24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1–2 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2–4 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2–3 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Warfarin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36–48<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.5–3 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4–6 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3–5 days \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1123038.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Pharmacological differences between oral anticoagulants.</p>" ] ] 7 => array:9 [ "identificador" => "tbl0040" "etiqueta" => "Table 8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Stangier et al.,<a class="elsevierStyleCrossRef" href="#bib1080"><span class="elsevierStyleSup">102</span></a> Kubitza et al.,<a class="elsevierStyleCrossRef" href="#bib1085"><span class="elsevierStyleSup">103</span></a> Garcia et al.,<a class="elsevierStyleCrossRef" href="#bib1090"><span class="elsevierStyleSup">104</span></a> Raghavan et al.<a class="elsevierStyleCrossRef" href="#bib1095"><span class="elsevierStyleSup">105</span></a> and Eriksson et al.<a class="elsevierStyleCrossRef" href="#bib1100"><span class="elsevierStyleSup">106</span></a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at8" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Half-life \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Peak plasma level \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Offset of action \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dabigatran \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12–14<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.25–3<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rivaroxaban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9–13<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2–4<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apixaban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10–14<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1–3<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1123039.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Pharmacological differences between novel oral anticoagulants.</p>" ] ] 8 => array:8 [ "identificador" => "tbl0045" "etiqueta" => "Table 9" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at9" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">FFP, fresh frozen plasma; FVIIa, activated factor <span class="elsevierStyleSmallCaps">VII</span>; NOAC, novel oral anticoagulants; OAC, oral anticoagulants; PCC, prothrombin complex.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OAC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NOAC \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Elective surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bridging therapy with LMWH: last therapeutic dose 24<span class="elsevierStyleHsp" style=""></span>h before surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interrupt 2–6 days before surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Emergency surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PCC<br>FFP (alternative)<br>FVIIa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PCC<br>Desmopressin, antifibrinolytics \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1123042.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Anticoagulant management in intracranial and spinal surgery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:114 [ 0 => array:3 [ "identificador" => "bib0575" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition)" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Chest" "fecha" => "2008" "volumen" => "133" "numero" => "6 Suppl." ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0580" "etiqueta" 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Journal Information
Vol. 63. Issue 7.
Pages 406-418 (August - September 2016)
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Vol. 63. Issue 7.
Pages 406-418 (August - September 2016)
Special article
Clinical practice guideline on thromboprophylaxis and management of anticoagulant and antiplatelet drugs in neurosurgical and neurocritical patients
Guía de práctica clínica sobre tromboprofilaxis y manejo de los fármacos anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y neurocríticos
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E. Vázquez-Alonsoa,
, F. Iturri Claverob, L. Valencia Solac, N. Fábregasd, I. Ingelmo Ingelmoe, R. Valerod, C. Cassinellof, P. Rama-Maceirasg, A. Jorquesh
Corresponding author
a Servicio de Anestesiología, Complejo Hospitalario Universitario Granada, Granada, Spain
b Servicio de Anestesiología, Hospital Universitario Cruces, Bilbao, Vizcaya, Spain
c Servicio de Anestesiología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
d Servicio de Anestesiología, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
e Servicio de Anestesiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
f Servicio de Anestesiología, Hospital Universitario Miguel Servet, Zaragoza, Spain
g Servicio de Anestesiología, Complejo Hospitalario Universitario Juan Canalejo, A Coruña, Spain
h Servicio de Neurocirugía, Complejo Hospitalario Universitario Granada, Granada, Spain
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Tables (9)
Table 2. Estimated grade of recommendation according to GRADE.
Table 3. Patient-related DVT risk factors.
Table 4. Thromboprophylaxis regimen.
Table 5. Pharmacological classification of antiplatelet agents.
Table 6. Antiplatelet drug management in intracranial and spinal surgery.
Table 7. Pharmacological differences between oral anticoagulants.
Table 8. Pharmacological differences between novel oral anticoagulants.
Table 9. Anticoagulant management in intracranial and spinal surgery.
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