Improvement of the perioperative clinical management by implementation of integrated protocol of perioperative substitution of oral anticoagulants

Muñoz-Corsini, L.; Herrero-Martin, S.; de la Fuente-Tornero, E.; Amorós-Alfonso, B.; de la Lastra-Iglesias, M.A.

doi:10.1016/j.redare.2018.02.006

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"apellidos" => "Amorós-Alfonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "M.A." "apellidos" => "de la Lastra-Iglesias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Grupo de Análisis de Incidentes Críticos, Servicio de Anestesiología y Reanimación, Hospital Universitario de Guadalajara, Guadalajara, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sección de Coagulación, Servicio de Hematología, Hospital Universitario de Guadalajara, Guadalajara, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mejoría de la gestión clínica perioperatoria mediante la implantación de un protocolo integrado de sustitución perioperatoria de anticoagulantes orales" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2939 "Ancho" => 2462 "Tamanyo" => 463355 ] ] "descripcion" => array:1 [ "en" => "Preoperative anticoagulation algorithm DOAC: direct-acting oral anticoagulants; INR: International Normalised Ratio; LMWH: low molecular weight heparin; OAC: oral anticoagulants; TKI: tyrosine kinase inhibitors; VKA: vitamin K antagonists." ] ] ] "textoCompleto" => "One of the commonest causes of adverse events and cancellations daily surgical practice is inadequate pre-surgical preparation of the patient. One of the most important aspects of pre-surgery preparation is adjustment of the patient's usual medication. This step is essential in patients taking oral anticoagulants (OAC). The risks associated with inadequate thromboembolism prophylaxis must be weighed up against the risk of severe perioperative bleeding. Optimising coagulation reduces the need for transfusion, the risk of local morbidity from bleeding in certain types of surgery, and thrombosis-related perioperative morbidity and mortality. It also reduces care costs and hastens the patient's return to normal life.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> Our hospital is a secondary level centre in Guadalajara serving around 250,000 inhabitants, more than of whom half live in rural areas served by nearly 30 health centres and 400 clinics. In our analysis of the reasons for surgical cancellation and OAC-related incidents, we detected several latent factors related with the risks inherent to these patients’ complex pathology. However, the reason was primarily poor communication between different specialists and between specialists and primary care doctors. This is confusing for patients and leads to inadequate pre-surgical OAC management. Based on these findings, specialists from the anaesthesiology and haematology departments developed a general pre-anaesthesia coagulation management protocol for all types of surgery, including outpatient procedures that links primary and specialised care (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The primary objective was to find a simple and reproducible formula based on classifying each patient according to their risk of thrombosis vs risk of surgery-induced bleeding.<a class="elsevierStyleCrossRefs" href="#bib0035">2,3</a> Following this, we defined 3 possible strategies: bridging anticoagulation with therapeutic-dose low-molecular-weight heparin (LMWH), bridging anticoagulation with prophylactic-dose prophylactic-dose LMWH, and no bridging therapy.<a class="elsevierStyleCrossRef" href="#bib0045">4</a> We developed 2 decision trees, one for patients taking vitamin K antagonists (VKA) and one for patients taking direct-acting OACs (DOAC). Patients with high thrombotic risk scheduled for high bleeding risk surgery were referred to haematology. The specific protocol to be followed in each case is given to the patient along with their general preoperative preparation instructions. One day before surgery, the patient takes their protocol to their primary care doctor, who verifies their INR levels and their compliance with the bridging therapy. If abnormalities are detected, oral vitamin K is administered. The protocol includes the type and dose of LMWH administered in each patient,<a class="elsevierStyleCrossRef" href="#bib0050">5</a> the patient's LMWH schedule according to the time the surgery is scheduled, and the OAC resumption regimen, which is fundamental in outpatient surgery. To make it easier for the patient to follow, the design of the schedule resembles that used in patients under chronic OAC treatment. In addition to giving the protocol to each patient, it was essential to introduce it to specialists and primary care doctors via video-conferencing and meetings, special presentations for the anaesthesiology department, the operating room committee and the primary care management board. Our objective was to evaluate whether implementation of this protocol reduced the rate of cancellations and adverse events related to OAC bridging therapy. We compared surgical cancellations due to poor management of OAC bridging strategies 19 months either side of implementation of the protocol. Our results show that the cancellation rate fell from 1.73 per month to 0.875 per month. The main reason for post-protocol cancellations was lack of follow-up by the attending anaesthesiologist, in 71.42% of cases. Incidents other than cancellations, which had previously occurred at an average rate of 1.10 per month, disappeared. These included delays in starting surgery, no medical indication to resume OCA after discharge home, and use of regional anaesthesia with no prior coagulation testing. Complex surgical procedures benefit from the development of evidence-based context-specific protocols that bridge the gap between specialist and primary care medicine, since patients will usually consult their primary care centre to resolve any doubts. These protocols must be updated periodically as new evidence becomes available.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Muñoz-Corsini L, Herrero-Martin S, de la Fuente-Tornero E, Amorós-Alfonso B, de la Lastra-Iglesias MA. Mejoría de la gestión clínica perioperatoria mediante la implantación de un protocolo integrado de sustitución perioperatoria de anticoagulantes orales. Rev Esp Anestesiol Reanim. 2018;65:238–240." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2939 "Ancho" => 2462 "Tamanyo" => 463355 ] ] "descripcion" => array:1 [ "en" => "Preoperative anticoagulation algorithm DOAC: direct-acting oral anticoagulants; INR: International Normalised Ratio; LMWH: low molecular weight heparin; OAC: oral anticoagulants; TKI: tyrosine kinase inhibitors; VKA: vitamin K antagonists." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative coagulation management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.T. Ganter" 1 => "D.R. Spahn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.bpa.2010.10.007" "Revista" => array:6 [ "tituloSerie" => "Best Pract Res Clin Anaesthesiol" "fecha" => "2010" "volumen" => "24" "paginaInicial" => "vii" "paginaFinal" => "viii" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21619860" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antiagregantes y anticoagulantes: manejo del paciente quirúrgico anticoagulado" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.V. Llau" 1 => "R. Ferrandis" 2 => "C. López Forte" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cir Esp" "fecha" => "2009" "volumen" => "85" "numero" => "Suppl 1" "paginaInicial" => "s7" "paginaFinal" => "s14" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative management of antithrombotic therapy: antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.D. Douketis" 1 => "A.C. Spyropoulos" 2 => "F.A. Spencer" 3 => "M. Mayr" 4 => "A.K. Jaffer" 5 => "M.H. Eckman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.11-2298" "Revista" => array:7 [ "tituloSerie" => "Chest" "fecha" => "2012" "volumen" => "141" "numero" => "Suppl 2" "paginaInicial" => "e326S" "paginaFinal" => "e350S" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22315266" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative management of oral anticoagulation: when and how to bridge" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. Dunn" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Thromb Thrombol" "fecha" => "2006" "volumen" => "21" "paginaInicial" => "85" "paginaFinal" => "89" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ficha técnica de la bemiparina. Available from: <a id="intr0010" class="elsevierStyleInterRef" href="http://www.aemps.gob.es/cima/fichasTecnicas">http://www.aemps.gob.es/cima/fichasTecnicas</a> [accessed 10.3.09]." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006500000004/v1_201804240407/S2341192918300234/v1_201804240407/en/main.assets" "Apartado" => array:4 [ "identificador" => "66474" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006500000004/v1_201804240407/S2341192918300234/v1_201804240407/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300234?idApp=UINPBA00004N"]

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Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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Vol. 65. Issue 4.