背景:在接受抗凝和抗血小板治疗的慢性疼痛患者中,介入技术的表现频率持续增加。了解持续慢性抗凝治疗的重要性,对介入技术的需求,确定抗凝治疗的持续时间和停药或暂时停药对避免破坏性并发症至关重要,主要是在进行神经轴手术时。抗凝剂和抗血小板作用于凝血系统,增加出血风险。然而,停用抗凝药物或抗血小板药物会使患者面临血栓形成风险,这可能导致显著的发病率和死亡率,尤其是那些患有冠状动脉或脑血管疾病的患者。这些指南总结了当前同行评审的文献,并根据在介入手术期间接受抗凝和抗血小板治疗的患者的最佳证据综合制定了基于共识的指南。
方法:基于最佳证据综合的文献综述和指南开发。
目的:对使用抗凝和/或抗血小板药物的患者在介入技术过程中出血和血栓形成风险评估的文献提供最新的和简明的评价。
方法:基于最佳证据综合制定共识指南,包括对介入疼痛过程中出血风险的文献进行回顾,实践模式,抗凝和抗血小板治疗的围手术期管理。一个多学科专家小组开发了方法论,基于最佳证据综合的风险分层,以及抗凝和抗血小板治疗的管理。它还包括基于多种因素的停止抗凝和抗血小板治疗的风险。出血风险的多个数据源,实践模式,血栓形成的风险,并确定了抗凝和抗血小板治疗的围手术期管理。从1966年到2023年,通过搜索多个数据库来确定相关文献。在制定共识声明和准则时,我们使用了一种改进的Delphi技术,这已经被描述为最小化与群体互动相关的偏见。没有主要利益冲突的小组成员投票批准了具体的指导方针声明。每位小组成员可以建议对指南声明的措辞进行编辑,并可以就指南在临床实践中的实施提出额外的限定意见或意见,以达成共识并纳入最终指南。每个指南声明都要求合格的小组成员之间至少有80%的同意,而没有主要的利益冲突。
结果:共有34位作者参与了这些指南的制定。其中,29人参加了投票。共提出了20项建议。总的来说,20个项目中的16个获得了100%的验收。经过第二轮和第三轮投票,项目总数减少到18个。最终结果为16项(89%)的100%接受。有2个陈述(陈述6和7)和3个作者的建议存在分歧。其余2个项目的接受度分别为94%和89%。分歧和异议是拜伦·J·施耐德,MD,建议将所有转孔药物分类为低风险,而SanjeevaGupta,MD,希望所有转孔药物都处于中等风险。第二个分歧与VivekanandA.Manocha有关,MD,建议颈部和胸部经椎间孔为高风险手术。因此,通过适当的文献综述,为接受抗凝药和抗血小板治疗的患者的围手术期管理制定了基于共识的声明。这些声明包括:血栓栓塞风险的估计,出血风险的估计,并确定重新开始抗凝或抗血小板治疗的时机。提供了风险分层,将介入技术分为三类低风险,中度或中度风险,和高风险。Further,在低风险和中等或中等风险类别的多种情况下,建议禁止停止抗凝治疗或抗血小板治疗.
结论:文献的持续缺乏与不一致的建议。
结论:根据现有文献的回顾,出版的临床指南,和建议,一个多学科专家小组介绍了围手术期接受抗凝或抗血小板治疗的患者的介入技术管理指南.这些指南提供了对风险分类的全面评估,适当的建议,以及基于现有最佳证据的建议。
BACKGROUND: The frequency of performance of interventional techniques in chronic pain patients receiving anticoagulant and antiplatelet therapy continues to increase. Understanding the importance of continuing chronic anticoagulant therapy, the need for interventional techniques, and determining the duration and discontinuation or temporary suspension of anticoagulation is crucial to avoiding devastating complications, primarily when neuraxial procedures are performed. Anticoagulants and antiplatelets target the clotting system, increasing the bleeding risk. However, discontinuation of anticoagulant or antiplatelet drugs exposes patients to thrombosis risk, which can lead to significant morbidity and mortality, especially in those with coronary artery or cerebrovascular disease. These
guidelines summarize the current peer reviewed literature and develop
consensus-based
guidelines based on the best evidence synthesis for patients receiving anticoagulant and antiplatelet therapy during interventional procedures.
METHODS: Review of the literature and development of guidelines based on best evidence synthesis.
OBJECTIVE: To provide a current and concise appraisal of the literature regarding the assessment of bleeding and thrombosis risk during interventional techniques for patients taking anticoagulant and/or antiplatelet medications.
METHODS: Development of
consensus guidelines based on best evidence synthesis included review of the literature on bleeding risks during interventional pain procedures, practice patterns, and perioperative management of anticoagulant and antiplatelet therapy. A multidisciplinary panel of experts developed methodology, risk stratification based on best evidence synthesis, and management of anticoagulant and antiplatelet therapy. It also included risk of cessation of anticoagulant and antiplatelet therapy based on a multitude of factors. Multiple data sources on bleeding risk, practice patterns, risk of thrombosis, and perioperative management of anticoagulant and antiplatelet therapy were identified. The relevant literature was identified through searches of multiple databases from 1966 through 2023. In the development of
consensus statements and
guidelines, we used a modified Delphi technique, which has been described to minimize bias related to group interactions. Panelists without a primary conflict of interest voted on approving specific guideline statements. Each panelist could suggest edits to the guideline statement wording and could suggest additional qualifying remarks or comments as to the implementation of the
guideline in clinical practice to achieve
consensus and for inclusion in the final
guidelines, each
guideline statement required at least 80% agreement among eligible panel members without primary conflict of interest.
RESULTS: A total of 34 authors participated in the development of these guidelines. Of these, 29 participated in the voting process. A total of 20 recommendations were developed. Overall, 100% acceptance was obtained for 16 of 20 items. Total items were reduced to 18 with second and third round voting. The final results were 100% acceptance for 16 items (89%). There was disagreement for 2 statements (statements 6 and 7) and recommendations by 3 authors. These remaining 2 items had an acceptance of 94% and 89%. The disagreement and dissent were by Byron J. Schneider, MD, with recommendation that all transforaminals be classified into low risk, whereas Sanjeeva Gupta, MD, desired all transforaminals to be in intermediate risk. The second disagreement was related to Vivekanand A. Manocha, MD, recommending that cervical and thoracic transforaminal to be high risk procedures.Thus, with appropriate literature review, consensus-based statements were developed for the perioperative management of patients receiving anticoagulants and antiplatelets These included the following: estimation of the thromboembolic risk, estimation of bleeding risk, and determination of the timing of restarting of anticoagulant or antiplatelet therapy.Risk stratification was provided classifying the interventional techniques into three categories of low risk, moderate or intermediate risk, and high risk. Further, on multiple occasions in low risk and moderate or intermediate risk categories, recommendations were provided against cessation of anticoagulant or antiplatelet therapy.
CONCLUSIONS: The continued paucity of literature with discordant recommendations.
CONCLUSIONS: Based on the review of available literature, published clinical guidelines, and recommendations, a multidisciplinary panel of experts presented guidelines in managing interventional techniques in patients on anticoagulant or antiplatelet therapy in the perioperative period. These guidelines provide a comprehensive assessment of classification of risk, appropriate recommendations, and recommendations based on the best available evidence.