Clinical protocols for oral anticoagulant reversal during high risk of bleeding for emergency surgical and nonsurgical settings: a narrative review
Protocolos clínicos para reversão de anticoagulante oral durante alto risco de sangramento para ambientes cirúrgicos e não cirúrgicos de emergência: uma revisão narrativa
Carlos Galhardo Jr., Luiz Henrique Ide Yamauchi, Hugo Dantas, João Carlos de Campos Guerra
Abstract
Background and objectives
Oral anticoagulants prevent thromboembolic events but expose patients to a significant risk of bleeding due to the treatment itself, after trauma or during surgery. Any physician working in the emergency department or involved in the perioperative care of a patient should be aware of the best reversal approach according to the type of drug and the patient’s clinical condition. This paper presents a concise review and proposes clinical protocols for the reversal of oral anticoagulants in emergency settings, such as bleeding or surgery.
Contents
The authors searched for relevant studies in PubMed, LILACS, and the Cochrane Library database and identified 82 articles published up to September 2020 to generate a review and algorithms as clinical protocols for practical use. Hemodynamic status and the implementation of general supportive measures should be the first approach under emergency conditions. The drug type, dose, time of last intake, and laboratory evaluations of anticoagulant activity and renal function provide an estimation of drug clearance and should be taken into consideration. The reversal agents for vitamin K antagonists are 4-factor prothrombin complex concentrate and vitamin K, followed by fresh frozen plasma as a second-line treatment. Direct oral anticoagulants have specific reversal agents, such as andexanet alfa and idarucizumab, but are not widely available. Another possibility in this situation, but with less evidence, is prothrombin complex concentrates.
Conclusion
The present algorithms propose a tool to help health care providers in the best decision making for patients under emergency conditions.
Keywords
Resumo
Justificativa e objetivos: Os anticoagulantes orais previnem eventos tromboembólicos, mas expõem os pacientes a um risco significativo de sangramento devido ao próprio tratamento, após trauma ou durante cirurgia. Qualquer médico que trabalhe no departamento de emergência ou envolvido no cuidado perioperatório de um paciente deve estar ciente da melhor abordagem de reversão de acordo com o tipo de medicamento e a condição clínica do paciente. Este artigo apresenta uma revisão concisa e propõe protocolos clínicos para a reversão de anticoagulantes orais em ambientes de emergência, como sangramento ou cirurgia. Conteúdo: Os autores buscaram estudos relevantes no PubMed, LILACS e na base de dados da Biblioteca Cochrane e identificaram 82 artigos publicados até setembro de 2020 para gerar uma revisão e algoritmos como protocolos clínicos para uso prático. O estado hemodinâmico e a implementação de medidas gerais de suporte devem ser a primeira abordagem em condições de emergência. O tipo de medicamento, a dose, o tempo da última ingestão e as avaliações laboratoriais da atividade anticoagulante e da função renal fornecem uma estimativa da depuração do medicamento e devem ser levados em consideração. Os agentes de reversão para os antagonistas da vitamina K são o concentrado do complexo de protrombina de 4 fatores e a vitamina K, seguidos por plasma fresco congelado como tratamento de segunda linha. Os anticoagulantes orais diretos têm agentes de reversão específicos, como andexanet alfa e idarucizumabe, mas não estão amplamente disponíveis. Outra possibilidade nessa situação, mas com menos evidências, são os concentrados de complexo de protrombina. Conclusão: Os algoritmos presentes propõem uma ferramenta para ajudar os profissionais de saúde na melhor tomada de decisão para pacientes em condições de emergência.
Palavras-chave
References
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