PDF(Pubmed)
Abstract：
Despite clear, relatively easy-to-use guidance, many clinicians find the preoperative management of direct oral anticoagulants (DOACs) challenging. Inappropriate management can delay procedures and lead to haemorrhagic or thromboembolic complications. We aimed to describe preoperative management practices regarding DOACs in a tertiary hospital and clinicians\' adherence to in-house recommendations.
We included all patients being treated with DOACs who underwent elective surgery in 2019 and 2020 (n = 337). In-house recommendations for perioperative management were largely comparable to the 2022 American College of Chest Physicians guidelines.
Typical patients were older adults with multiple comorbidities and high thrombotic risk stratification scores, and 65.6% (n = 221) had not undergone recommended preoperative anticoagulation management protocols. Patients operated on using local anaesthesia (adjusted OR = 0.30, 95%CI 0.14-0.66; p < 0.01) were less likely to have been treated following institutional recommendations, but no association between their procedure\'s bleeding risk and adherence was found. Clinicians\' failures to adhere to recommendations mostly involved late or non-indicated interruptions of anticoagulation treatment (n = 89, 26.4%) or inappropriate heparin bridging (n = 54, 16.0%). Forty-five (13.3%) procedures had to be postponed. Incorrect preoperative anticoagulation management was directly responsible for 12/45 postponements (26.7% of postponements).
This study highlights clinicians\' low adherence rates to institutional recommendations for patients treated with DOACs scheduled for elective surgery in a tertiary hospital centre. To the best of our knowledge, this is the first clinical study addressing the issue of clinicians\' adherence to guidelines for the preoperative management of DOACs. Going beyond the issue of whether clinicians are knowledgeable about guidelines or have them available, this study questions how generalisable guidelines are in a tertiary hospital managing many highly polymorbid patients. Further studies should identify the causes of poor adherence.
We included all patients being treated with DOACs who underwent elective surgery in 2019 and 2020 (n = 337). In-house recommendations for perioperative management were largely comparable to the 2022 American College of Chest Physicians guidelines.
Typical patients were older adults with multiple comorbidities and high thrombotic risk stratification scores, and 65.6% (n = 221) had not undergone recommended preoperative anticoagulation management protocols. Patients operated on using local anaesthesia (adjusted OR = 0.30, 95%CI 0.14-0.66; p < 0.01) were less likely to have been treated following institutional recommendations, but no association between their procedure\'s bleeding risk and adherence was found. Clinicians\' failures to adhere to recommendations mostly involved late or non-indicated interruptions of anticoagulation treatment (n = 89, 26.4%) or inappropriate heparin bridging (n = 54, 16.0%). Forty-five (13.3%) procedures had to be postponed. Incorrect preoperative anticoagulation management was directly responsible for 12/45 postponements (26.7% of postponements).
This study highlights clinicians\' low adherence rates to institutional recommendations for patients treated with DOACs scheduled for elective surgery in a tertiary hospital centre. To the best of our knowledge, this is the first clinical study addressing the issue of clinicians\' adherence to guidelines for the preoperative management of DOACs. Going beyond the issue of whether clinicians are knowledgeable about guidelines or have them available, this study questions how generalisable guidelines are in a tertiary hospital managing many highly polymorbid patients. Further studies should identify the causes of poor adherence.
摘要：
背景：尽管很清楚，相对易于使用的指导，许多临床医生发现直接口服抗凝剂(DOACs)的术前处理具有挑战性.不适当的管理会延迟程序并导致出血或血栓栓塞并发症。我们旨在描述三级医院中DOAC的术前管理实践以及临床医生对内部建议的遵守情况。
方法：我们纳入了2019年和2020年接受DOAC治疗的所有患者（n=337）。关于围手术期管理的内部建议在很大程度上与2022年美国胸科医师学会指南相当。
结果：典型患者为具有多种合并症和高血栓危险分层评分的老年人，65.6%(221例)未接受推荐的术前抗凝治疗方案.使用局部麻醉（校正后的OR=0.30，95CI0.14-0.66；p<0.01）的患者不太可能按照机构建议进行治疗。但未发现他们的手术出血风险与依从性之间存在关联。临床医生未能遵守建议主要涉及抗凝治疗的后期或无指示中断（n=89，26.4％）或肝素桥接不当（n=54，16.0％）。45（13.3％）的程序必须推迟。不正确的术前抗凝管理是12/45延迟的直接原因（延迟的26.7％）。
结论：本研究强调，对于在三级医院中心进行择期手术的DOAC治疗患者，临床医生对机构建议的依从性较低。据我们所知,这是第一项临床研究,旨在解决临床医师对DOAC术前管理指南的依从性问题.超越了临床医生是否了解指南或是否可用的问题，这项研究质疑在管理许多高度多态患者的三级医院中,指南的普遍性.进一步的研究应该找出依从性差的原因。
方法：我们纳入了2019年和2020年接受DOAC治疗的所有患者（n=337）。关于围手术期管理的内部建议在很大程度上与2022年美国胸科医师学会指南相当。
结果：典型患者为具有多种合并症和高血栓危险分层评分的老年人，65.6%(221例)未接受推荐的术前抗凝治疗方案.使用局部麻醉（校正后的OR=0.30，95CI0.14-0.66；p<0.01）的患者不太可能按照机构建议进行治疗。但未发现他们的手术出血风险与依从性之间存在关联。临床医生未能遵守建议主要涉及抗凝治疗的后期或无指示中断（n=89，26.4％）或肝素桥接不当（n=54，16.0％）。45（13.3％）的程序必须推迟。不正确的术前抗凝管理是12/45延迟的直接原因（延迟的26.7％）。
结论：本研究强调，对于在三级医院中心进行择期手术的DOAC治疗患者，临床医生对机构建议的依从性较低。据我们所知,这是第一项临床研究,旨在解决临床医师对DOAC术前管理指南的依从性问题.超越了临床医生是否了解指南或是否可用的问题，这项研究质疑在管理许多高度多态患者的三级医院中,指南的普遍性.进一步的研究应该找出依从性差的原因。
