Uued antikoagulandid e. NOA-d (DOAC`d) perioperatiivses situatsioonis.
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1 Uued antikoagulandid e. NOA-d (DOAC`d) perioperatiivses situatsioonis. Indrek Rätsep PERH Antitrombootilise ravi perioperatiivsest käsitlusest sõltub: VeritsusRISK Kirurgiline veritsus Anesteesia valik (Spinaalhematoomi tekkerisk) Tromboosi RISK Kardio-tserebraalne trombemboolia (koronaarsündroom, insult) VTE (venoosne trombemboolia) 1
2 Antikoagulantravi 2 näidustust NOA-dega: Süsteemse trombemboolia ennetamine Kodade virvendusarütmia, FA korral Kopsuarteri trombemboolia ennetamine Venoosse trombembolismi (VTE) profülaktika Miks uued suukaudsed AK-d? Kui varfariinravi on raskesti teostatav. Dabigatraanil (Pradaxa), rivaroksabaanil (Xarelto), and apiksabaanil (Eliquis) on stabiilne farmakokineetiline ja dünaamiline profiil, mis võimaldab neid manustada monitooringuta. Uuringutes näidatud, et pole halvem või on isegi tõhusam kui warfariin (Marevan). Ohutusprofiil on parem kui varfariinil. Monitooring võib olla vajalik hädaolukorras kui vajalik kirurgia või on verejooks. 2
3 Koagulatsioonikaskaad Trombi tekkeprotsess tervikuna 3
4 Laboratoorsed testid. Plasma kontsentratsioone määratakse juhul kui: Verejooks Üledoos Tekkinud neerupuudulikkus Tekkinud tromboos! Erakorraline kirurgia 4
5 Määratakse aegasid, mida NOA mõjutab 5
6 Ravi katkestamine enne OP-i NB! NOA-sid ei sillata! Kuidas praktikas meelde jätta? 1-2 päeva kui normaalne neerufunktsioon (sõltuvalt kirurgiast) päeva kui kreatiniini kliirens < 30 ml, pikim aeg vajalik dabigatraanil ja suure veritsusriskiga protseduuriks. 6
7 APTT PT & INR antixa TT Kasutatavad testid on: Normaalne TT välistab Dabi toime, kuid annuse tiitrimiseks on liiga tundlik, Ekariini aeg tulekul.. Riva ja Api hindamiseks sobib anti Xa, vajalik spets. kalibratsioon laboris 7
8 NOA de lõpetamine ja tromboosirisk ESA Ravijuhis Recommendations we recommend to assess creatinine clearance in patients receiving NOAs and being scheduled for surgery. 1B We suggest that NOAs should not be interrupted for skin surgery, dental and other oral procedures, gastric and colonic endoscopies (even if biopsy is scheduled, but not polypectomy), nor for most ophthalmic surggery. 8
9 Stop sildamiseta We recommend that for low-risk patients (e.g. Atrial fibrillationpatients with CHADS2 score 2, patientstreated for >3 months for a nonrecurrent VTE) undergoing procedures requiring normal coagulation, NOAs can be stopped 5 days before surgery. No bridging therapy is needed. 1C Stop sildamisega In patients treated with rivaroxaban, apixabanand in patients treated with dabigatranifcreatinineclearance is higher than 50 ml/min,we suggestbridging therapy for high-risk patients: (e.g. atrial fibrillationpatients with a CHADS2 score >2, patients withrecurrent VTE treated for <3 months). Day -5: last NOAdose; Day -4: no heparin; Day -3and -2: therapeutic dose oflmwh; Day -1: last injection LMWH (in the morning, i.e. 24 h before the procedure), hospitalisationand measurement of dilutedthrombin time or specific anti-fxa; Day 0: surgery. 2C 9
10 Intervall ravimi ja neuraksiaalse blokaadi vahel: RA ja antikoagulatsioon, EAS 2011, Sisukord 1. Sissejuhatus Spinaalhematoom: määratlus ja tekkerisk Spinaalhematoomi riski vähendamine Fraktsioneerimata hepariin Madalmolekulaarne hepariin Teised trombiini või Xa faktori inhibiitorid Suukaudsed antikoagulandid (varfariin) Trombotsüütide agregatsiooni mõjutavad ravimid Antiagregantide ja antikoagulantide kombineerimine Trombolüütilise/fibrinolüütilise raviga seotud veritsused Millal uuesti alustada? rivaroksabaan 10
11 Testid VEREJOOKS Toime neutraliseerimine verejooksu korral loom- ja inimuuringutes Dabigatraan 1 x päevas 4-faktori protrombiini kompleks PCC (Octaplex) doosis U/kg omas efekti Aktiveeritud protrombiini kompleks apcc (FEIBA) doosis U/kg veelgi parem toime. Dabigatraan 2 x päevas PCC (Octaplex) 50 U/kg ei korrigeerinud pikenenud aptt, ega TT väärtusi, ka suuremad doosid mitte! In vitro taastas need väärtused apcc (FEIBA, s.o. faktor 7+ 3PCC) Rivaroksabaan 1 x päevas Octaplex 50 U/kg normaliseeris PTT väärtuse 11
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14 Milline võiks olla tegutsemisalgoritm Eesti haiglates.. Hinnata ravimi doosi ja patsiendi neerufunktsiooni. Dabigatraani korral dialüüs või forsseeritud diurees. Hinnata aega viimasest tarvitamiset. Manustada hüübimisfaktoreid (krüo, PCC). Manustada prokoagulatiivseid preparaate nagu apcc ja rfviia (suurem oht trombootilisteks tüsistusteks!) Tulevik Täpsem labordiagnostika Ecariini aeg Dabigatraanile Kalibreeritud antixa Rivaroksabaanile Täpsed antidoodid Monoklonaalsed antikehad Dabi-le Faktor Xa, selleks et siduda anti Xa 14
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