Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 868 - файл
.pdf
74
https://t.me/med1917
Table 5.1 (continued)
Restart after
Hold before
neuraxial/deep
Medication
Ticagrelor 5–7days Immediately if
Ticlopidine 10days Immediately if
tPA Avoid Avoid No
Urokinase Avoid Avoid No
Warfarin 5days and
dTT/ECT dilute thrombin time/ecarin clotting time, INR international normalized ratio
peripheral block
normal INR
neuraxial/deep
peripheral
block
no loading
dose
no loading
dose
No delay INR<1.5,
Hold before
neuraxial/
peripheral
catheter removal
Avoid Immediately if no
6h, if loading
dose is given
recommendation
recommendation
12–24h
INR>3, hold or
reduce dose with
indwelling
catheters
1.5<INR<3,
maintain catheter
with caution
C. Karam et al.
Restart after
neuraxial/
peripheral
catheter removal
loading dose
Immediately if no
loading dose
No
recommendation
No
recommendation
No delay
Non-cardiac Surgery inPatients onDual Antiplatelets or
onAnticoagulation
Percutaneous coronary intervention (PCI) necessitates treatment with dual antiplatelet therapy (aspirin and P2Y12 receptor inhibitors) for a variable duration after
the procedure, depending on the type of PCI.
Certain conditions such as atrial brillation, history of deep vein thrombosis, and
pulmonary embolism, or the presence of mechanical heart valves, require long-term
anticoagulation to prevent the risk of thrombosis and embolism that may result in
cerebrovascular accidents, heart failure, and death. Traditionally, warfarin is used
for chronic anticoagulation, yet more recently, newer direct thrombin inhibitors or
factor X inhibitors are becoming more popular.
In the case of either dual antiplatelet therapy or chronic anticoagulation, the risk
of excessive surgical bleeding if the medications are continued versus the drastic
consequences of withholding the medications has to be balanced.
5 Managing the Patient on Antiplatelet, Anticoagulation, Beta Blockers…
https://t.me/med1917
75
Patients withRecent Cardiac Stents onAntiplatelet Therapy
Non-cardiac surgery following recent PCI with stenting is a risk factor for major
cardiac events, including myocardial infarction and stent thrombosis [22]. Dual
antiplatelet medications are usually prescribed after PCI to decrease the above risks.
Hence, withholding dual antiplatelet therapy prematurely contributes to the risk of
increased stent thrombosis, myocardial infarction, and death, especially during the
prothrombin state associated with the perioperative period [23, 24]. Consequently,
maintaining dual antiplatelet therapy may contribute to excessive surgical bleeding,
which is more relevant in surgeries with high risk of bleeding like prostate and neurosurgical interventions. The risk for excessive surgical bleeding becomes less relevant if the surgery is minor, such as cataract extraction.
There are multiple types of stents used during PCI. The latter usually dictates the
duration of dual antiplatelet therapy. While the detailed characteristics of the stent
types goes beyond the scope of this discussion, it is important to note one major
difference; as we progress from bare metal stents to newer drug-eluting stents, the
risk of restenosis and late thrombosis decreases [25]. The decision to withhold or
maintain dual antiplatelet therapy in the perioperative period depends not only on
the type of cardiac stent, but also on the time elapsed between the PCI and the date
of surgery, as well as the risk of bleeding associated with the specic surgery. In this
regard, the American College of Cardiology /American Heart Association (ACC/
AHA) task force provided guidelines in 2014. It is recommended that elective surgery be postponed 30days and 360days after PCI for bare metal stents and drugeluting stents, respectively (Class 1 level B evidence) [23]. Of note, the period of
360days or 30days represents the optimal time associated with the lowest incidence of major cardiac events [26]. This also corresponds to the time after which
dual antiplatelet therapy would have been stopped and the patient would be solely
maintained on aspirin. Hence, both the risk of bleeding and major cardiac events is
decreased. If stent implantation is less than 4–6weeks before a necessary or a lifesaving surgery, it is recommended to proceed with the surgery without stopping
dual antiplatelet therapy, unless the risk of bleeding during the surgery outweighs
the risk of stent thrombosis (Class 1 level C evidence) [23]. If stent placement is
more than 30days but less than 360days for drug-eluting stents, it is recommended
to proceed with the surgery after 180days if and only if the risk of delaying the
surgery is greater than the risk of stent thrombosis (Class 2B) [23]. If the risk of
thrombosis is higher than the risk of delaying the surgery, it is recommended to
postpone the surgery to the optimal time of 360days (Class 1) [23]. If a patient with
coronary stents needs to undergo a surgery that requires discontinuation of the
P2Y12 platelet receptor inhibitors, it is recommended that aspirin be continued if the
type of surgery allows for that, and that the P2Y12 platelet receptor inhibitors be
resumed as soon as possible (Class 1 level of evidence C) [23]. In a patient without
coronary stents, it may be reasonable to discontinue aspirin therapy before surgery
(Class 3 level B evidence) [23]. However, if the risk of ischemic events outweighs
the risk of bleeding, it may be reasonable to continue aspirin (Class 3 level of evidence C) [23].
76
https://t.me/med1917
With regard to clopidogrel/prasugrel, they need to be discontinued at least 5days
before surgery. Aspirin, on the other hand, needs to be discontinued for a minimum
of 7days if mandated by the risk of surgical bleeding. Antiplatelet therapy is typically resumed 24h postoperatively [27].
With the development of the second-generation of drug-eluting stents, the risk of
stent thrombosis was reduced. Accordingly, the ACC/AHA published in 2016 an
update on their previous guidelines, stating that among patients who had a secondgeneration drug-eluting stent placement within 3–6 months of surgery, one may
consider the discontinuation of the second antiplatelet drug, while maintaining aspirin, and accordingly proceed with the surgery if the risk of delayed surgery is greater
than the risk of stent thrombosis [28] (as opposed to at least 180days in the 2014
guidelines). As for elective non-cardiac surgery in patients treated with secondgeneration drug-eluting stents, proceeding with the surgery and discontinuation of
one antiplatelet may be considered after 180days [28] (as opposed to 360days in
2014 guidelines). However, it is not only important to determine the time since the
PCI was performed, but also one has to consider the reasons behind it, namely if it
was electively placed or secondary to an acute coronary event. The 2014 European
Society of Cardiology/European Society of Anesthesiology (ESC/ESA) guidelines
recommend dual antiplatelet therapy to be continued for three to 12months following new-generation drug-eluting stent placement and becomes preferable for 1year
after a PCI performed for acute coronary event, unless the risk of life-threatening
surgical bleeding is unacceptably high [24] (Class 2a level of evidence C). The
major recommendations are summarized in Table5.2.
To sum up, the decision to continue dual antiplatelet therapy in the perioperative
period depends on many factors, including the time from PCI, the type of cardiac
stent, the pathology that led to the PCI, the risk of surgical bleeding, and the risk for
thrombosis. Since multiple factors are involved, it is important to establish a proper
collaboration between the anesthesiologist, the cardiologist, and the surgeon in
order to make an informed decision concerning the management of dual antiplatelet
therapy in the perioperative period.
C. Karam et al.
Patients onChronic Anticoagulation Therapy
Patients with atrial brillation, mechanical heart valves, history of deep vein thrombosis, or pulmonary embolism require treatment with oral anticoagulation, whether
warfarin or novel anticoagulation. The risk of bleeding must be weighed against the
benet of maintaining anticoagulants on a case-by-case basis. Whenever the risk of
bleeding is minimal or mild, such as cataract surgery or minor dermatologic procedures, it may be reasonable to continue anticoagulation preoperatively [27, 29].
However, for surgeries with a high risk of bleeding, the decision becomes more
challenging, as one needs to keep the patient anticoagulated for the longest period
possible, without signicantly increasing the risk of excessive surgical bleeding.
Patients at low risk for thromboembolism should not create a dilemma, as the
oral anticoagulation can be comfortably withheld [27, 29]. Bridging therapy is
5 Managing the Patient on Antiplatelet, Anticoagulation, Beta Blockers…
https://t.me/med1917
Table 5.2 Summary of the recommendations concerning the management of patients with recent
cardiac stents on dual antiplatelet therapy [23, 24, 28]
Type of surgery
Elective surgery Postpone surgery
Urgent or lifesaving surgery
4–6weeks after PCI
Surgery more than 30days but
less than 360days from PCI and
risk of delaying surgery is higher
than risk of stent thrombosis
Surgery more than 30days but
less than 360days from PCI and
risk of thrombosis higher than risk
of delaying surgery
Proceeding with the surgery usually requires the discontinuation of the P2Y12 platelet receptor
inhibitors and maintaining aspirin if risk of bleeding is acceptable
PCI percutaneous coronary intervention
Bare metal stents
30days from PCI
Proceed with
surgery without
stopping dual
antiplatelet
Proceed with
surgery
Proceed with the
surgery
Drug-eluting stents
Postpone surgery 360days from
PCI if rst-generation drug-eluting
stent
Postpone surgery 180days if
second-generation drug-eluting
stent
Postpone surgery 360days if stent
placement performed for acute
coronary event
Proceed with surgery without
stopping dual antiplatelet
Proceed with surgery 180days after
PCI with rst-generation stents, and
90–180days after PCI with
second-generation stents
Postpone surgery 360days after
PCI with rst-generation stents
Postpone surgery 180days after
PCI with second-generation stents
77
considered for patients with a high risk for thromboembolism without excessive
risk of bleeding [27, 29]. The concept of bridging consists of replacing warfarin
with intravenous unfractionated heparin (UFH) or LMWH during the perioperative period since these medications have a shorter duration of action than warfarin
and can be stopped at a shorter interval from surgery. This is particularly useful
for patients at high risk of thromboembolism. Warfarin is usually stopped at least
5days prior to an elective surgery to achieve a normal INR prior to surgery. An
INR more than 1.5 justies vitamin K administration, in order to reverse the effect
of warfarin. If immediate reversal of warfarin’s effect needs to be done, fresh
frozen plasma should be administered [27]. The preferred bridging therapy is usually subcutaneous LMWH or intravenous UFH.The last dose of LMWH should
be halved and should be given 24h before surgery. UFH should be 4–6h before
surgery [27]. Antithrombic therapy should be resumed 24 h post-surgery for
patients at low risk of bleeding and 48–72h for patients at high risk for bleeding
[27, 30, 31].
Patients with intermediate risk of thromboembolism should be managed on a
case-by-case basis. The landmark BRIDGE trial showed that bridging in moderaterisk atrial brillation population may cause harm without benets. This study
showed that in this population, no bridging does not increase the risk of thromboembolism; however, it decreases the risk of bleeding [32].
78
https://t.me/med1917
Concerning novel anticoagulation agents like direct thrombin inhibitors and
direct factor X inhibitors, multiple studies have investigated perioperative interruption of these drugs among patients with atrial brillation [33–37]. None of these
studies found an increased risk of thromboembolism or bleeding preoperatively
regardless of bridging therapy, or the type of surgery [34, 35]. However, experience
with these novel agents is still limited, and there are no answers yet as to whether
the continuation of novel anticoagulation agents increases the risk for surgical
bleeding. In addition, the exact safe timing for resuming these agents postoperatively is still unclear [35]. Further studies are required to devise safe perioperative
regimens for these medications. So far, a conservative approach of no bridging is
usually adopted in order to reduce the risk of perioperative bleeding as much as possible, in the absence of evidence [38].
C. Karam et al.
Perioperative Management ofPatients
onAntihypertensive Medications
Beta Blockers
Surgical stress is usually associated with physiological responses that may
adversely affect patients’ outcomes. Beta blockers are usually used to alleviate the
stress response, mainly tachycardia, with a proven benet in the intensive care
unit or in burned patients [39]. However, perioperative management of beta blockers is still unclear. The numerous trials addressing preoperative beta blockers
resulted in conicting results. For many years, beta blockers were stopped before
surgery because of concerns about negative inotropic effects. This is until
Mangano etal. demonstrated a benecial role of beta blockers (atenolol) started
30min in the preoperative period for non-cardiac surgery and continued 7days
postoperatively. The study proposed that beta blocker use could reduce cardiac
adverse events and improve recovery outcomes [40]. This was followed by the
Decrease I trial by Poldermans etal. that revealed signicant decrease in serious
cardiac events and nonfatal myocardial infarction (MI) with bisoprolol [41].
These studies showed promising results concerning the use of beta blockers in the
perioperative period. Moreover, the POISE study, with around 9000 participants,
demonstrated that perioperative beta blocker use (metoprolol) started 2–4h before
surgery until 30days postoperatively decreases nonfatal MI.However, this study
also showed a signicant increase in the number of deaths because of a higher
incidence of hypotension, bradycardia, and stroke [42]. Despite those alarming
results, the Decrease IV trial demonstrated a benecial role of bisoprolol in the
reduction of nonfatal MI and risk of cardiac death in intermediate- risk patients
undergoing non-cardiac surgery [43]. It is noteworthy to mention that most of the
trials studied the effect of beta blockers started within 1day or less before noncardiac surgery. The Decrease trials were the only studies that assessed beta
blocker use 2 or more days before surgery, and thus their results differed signicantly from other trials [44]. However, the Decrease trials had their integrity
5 Managing the Patient on Antiplatelet, Anticoagulation, Beta Blockers…
https://t.me/med1917
79
questioned [45] and the POISE trial was criticized for the use of high-dose, longacting beta blockers and for initiation of the dose immediately before non- cardiac
surgery. Other studies that used a lower starting dose showed no harm nor benet
[46–48].
In the presence of conicting results, the ACC/AHA published guidelines on
beta blockers use in the perioperative period in 2009. The main message was that
patients already on beta blockers prior to surgery should keep taking them perioperatively (class IC) [49]. Patients with known ischemic heart disease or MI and
those undergoing high-risk surgery including vascular surgeries should start beta
blockers in the perioperative period (class II) [49]. Titration of beta blockers in
naïve patients was also stressed (class III recommendations) [49].
In 2014, the perioperative guidelines were revised by the ESC and ACC/
AHA.Most of the recommendations that required revision were not supported by
evidence; the systematic reviews did not yield to conrmative results because of
insufcient data on beta blockade start and controversial results regarding the effects
on all-cause and cardiovascular death among studies. Also the exclusion of the
decrease trials and POISE trial leaves few data to draw solid conclusions. The
guidelines were based mainly on expert opinion and pharmacological properties of
the drug.
Multiple parameters should be considered when perioperative beta blocker therapy is being evaluated. The discrepancy in the effects of beta blockers is attributed
to different variables. These include age, gender, comorbidities, type of surgery,
beta blocker type, dose, titration, administration (initiated/continued/withdrawn)
and the endpoint in question (mortality, stroke, MI). Treatment should be individualized for every single patient. Bradycardia and hypotension should be avoided, thus
the importance of drug titration to appropriate heart rate (60–70bpm) and blood
pressure (SBP>100mmHg and MAP>55mmHg) targets. Strategies for the use of
beta blockers before surgery have been changing and evolving over time. Very few
studies have emerged within recent years; therefore, the 2014 guidelines included
most of the available studies.
Continuing beta blockers in patients taking them for symptomatic cardiovascular
disease remains unchallenged (class I) [23, 24]. Initiation of beta blockers before
non-cardiac surgery is controversial. A cardiac benet is present at the expense of
increased death and stroke, whereas in patients with three or more revised cardiac
risk index (RCRI) risk factors, it may be reasonable to start beta blockers before
surgery (class IIB) [23, 24]. Treatment effects of perioperative beta blockade vary
across patients, with benets conned to high-risk individuals (ASA equal or more
than 3). It is not recommended to start beta blockade on low-risk surgery (class III)
[23, 24].
Beta blocker initiation should ideally begin 1week and up to 30 days before
surgery and should never be started on the same morning. Atenolol or bisoprolol are
considered as rst-choice oral beta blockers (class IIb) in ESC [24] but not ACC/
AHA recommendations. The lack of evidence of systematic differences in perioperative risks with specic beta blockers subtype makes this current recommendation
questionable.
80
https://t.me/med1917
In 2018, a meta-analysis of 88 randomized controlled trials (53 trials of cardiac
surgeries and 35 trials of non-cardiac surgeries) included around 20,000 participants. The main ndings were as follows [50]. The role of beta blockers in cardiac
surgery is essential for supraventricular and ventricular arrhythmias reduction,
whereas their role with respect to mortality, MI, stroke, congestive heart failure,
hypotension, and bradycardia is still unclear. In those taking beta blockers, the
length of hospital stay after heart surgery was reduced by half a day. In cardiac surgery, there seems to be an overall benet in the use of beta blockade, as it is protective against postoperative rhythm disturbances. Current evidence recommends that
patients should continue beta blockers before elective and non-elective heart surgery (class IIa level B). One should consider switching to short-acting agents, and
careful up-titration is recommended to limit adverse events. Beta blockers are most
benecial in patients with a recent MI. Preoperative beta blockers use among
patients who didn’t have a recent MI was not associated with improved perioperative outcomes. It is still unclear if patients with low ventricular ejection fraction
(LVEF) but without a recent MI should be started preoperatively on beta blockers.
It is crucial to continue beta blockers in patients with a recent MI or low LVEF in
the perioperative period, as it signicantly reduces the 30-days’ mortality (class I
level A). Metoprolol succinate, bisoprolol, nebivolol, and carvedilol are accepted
beta blockers choices. In non-cardiac surgery, the above review showed that the
reduction in rhythm disturbances and non-fatal MI is offset by the potential increase
in mortality, stroke, hypotension, bradycardia, and sepsis [50].
In conclusion, the only available class I recommendation is to continue beta
blockers in patients chronically treated. The remaining recommendations are weak
(class IIb) [50]. The quality of evidence is still low to moderate. As a result, more
research is needed before stronger recommendations can be issued.
C. Karam et al.
Angiotensin-Converting Enzyme Inhibitors
andAngiotensin-Receptor Blockers
High-risk surgical patients are frequently on angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers (ACEi and ARB). Their role in hypertension,
heart failure, ischemic heart diseases, diabetes mellitus, and renal disease is well
recognized. However, there is conicting data about their perioperative management. Theoretically, ACEi/ARBs blunt the renin-angiotensin system during surgery
and result in profound hypotension. Preoperative treatment with this class of medications was associated with an increased incidence of intraoperative hypotension
[51, 52] and with major perioperative morbidity [53]. Conversely, continuation of
the ACEi/ARB therapy may have improved outcome in patients undergoing vascular surgery who have sustained a perioperative myocardial infarction [54]. In a study
including 79,000 patients, Turan etal. did not nd any association between the use
of ACEi and in-hospital complications or increased 30-day mortality [55]. An
observational cohort study of almost 15,000 patients concluded that withholding
ACEi/ARBs 24 h before major non-cardiac surgery was associated with a lower
5 Managing the Patient on Antiplatelet, Anticoagulation, Beta Blockers…
https://t.me/med1917
81
30-day all cause death, stroke, myocardial injury, and intraoperative hypotension
[53]. Vaquero Roncero etal. concluded that withholding AECI/ARBs on the morning prior to surgery could be recommended with a low level of evidence in order to
reduce hypotension in the perioperative period of non-cardiac surgery [56]. A metaanalysis of more than 6000 patients undergoing non-cardiac surgery did not nd an
association between perioperative administration of ACEi/ARBs and mortality or
major cardiac events. However, withholding these medications preoperatively is
associated with signicant decrease in intraoperative hypotension [57]. Shiffermiller
et al. demonstrated that transient preoperative interruption of ACEI therapy in
patients undergoing non-cardiac surgery is associated with a decreased risk of intraoperative hypotension. However, postoperative hypertensive events were more frequent [58].
There are various conicting recommendations regarding perioperative management of ACEi/ARBs in patients undergoing non-cardiac surgery. The ESC/ESA
2014 guidelines are all of class IIa. They recommend continuing ACEi or ARB
therapy in stable patients with heart failure undergoing non-cardiac surgery under
close monitoring, whereas their transient discontinuation in hypertensive patients
should be considered [24]. The ACC/AHA guidelines in 2014 are of class IIa as
well and recommend the continuation of ACEi/ARBs in the perioperative period
and, if withheld before surgery, it is reasonable to restart as soon as clinically feasible [23]. The French Society of Anesthesiologists guidelines in 2012 recommends
discontinuation of ACEi/ARBs administered for hypotension >12h before surgery,
but no discontinuation in case of heart failure [59].
Additional studies evaluated the effect of ACEi/ARBs in patients undergoing
cardiac surgery. Benedetto etal. and Drenger etal. suggested a possible myocardial
protective effect of ACEi in patients undergoing coronary artery bypass grafting
(CABG) surgery [60, 61]. Multiple studies showed conicting results concerning
the effect of ACEi on acute kidney injury after CABG [62–64]. It has been debated
whether ACEi should be discontinued before CABG.The exact timing of discontinuation and reinstitution is poorly studied. It is believed that ACEi/ARBs increase
the risk of perioperative hypotension and vasodilatory shock, thus requiring the use
of inotropes and vasopressors, which will lead to extended intensive care unit stay
and ventilator-dependent time [65]. Van Diepen etal. concluded that the routine
continuation or discontinuation of ACEi/ARBs before cardiac surgery was not associated with differences in the postoperative physiological or clinical outcomes [65].
The European Association for Cardio-Thoracic Surgery (EACTS) 2017 guidelines recommend discontinuing ACEi/ARB’s perioperatively in patients undergoing
cardiac surgery (Class I) [66]. Whereas in patients with uncontrolled hypertension,
it is reasonable to switch long-acting ACEi or ARB treatment to short-acting ACEi
(Class IIa) [66]. In the postoperative period, ACEi/ARBs have protective effects in
patients with reduced LVEF and impaired kidney function post CABG [66]. In
those patients, it should be considered to start short-acting ACEi no earlier than 48h
(Class IIa) [66]. In ACEi-intolerant patients, an ARB is recommended (Class I)
[66]. For other patients without hypertension or reduced LVEF, the routine use of
ACEi is not recommended, as it may increase potential adverse events [66].
82
https://t.me/med1917
Table 5.3 Summary of the recommendations concerning the management of antihypertensive
medications in the perioperative period [23, 24, 50, 66]
Medication
Beta
blockers
ACEi/
ARB
MI myocardial infarction, LVEF left ventricular ejection fraction, ACEi/ARB angiotensin-
converting enzyme inhibitor/angiotensin-receptor blocker
Non-cardiac surgery
Maintain beta blockers for patient
already on beta blockers for
symptomatic cardiovascular
disease
Initiation of beta blockers is
controversial
Maintain ACEi/ARB therapy in
patients with heart failure
Withholding ACEi/ARB therapy
in hypertensive patients is
reasonable
Cardiac surgery
Maintain beta blockers before elective and
non-elective heart surgery
Continuing beta blockers is crucial in patients
with recent MI or low LVEF; initiation of
beta blockers preoperatively is reasonable in
these patients
Maintain ACEi/ARB therapy in patients with
uncontrolled hypertension, reduced LVEF
and impaired kidney function
Withhold therapy in patients with controlled
blood pressure and normal LVEF
C. Karam et al.
Most ndings suggest that continuing ACEi/ARB therapy in the perioperative
period increases the incidence of perioperative hypotension. For the majority of
patients, it is usually recommended to withhold them on the day of surgery. However,
it is reasonable to continue them in patients with heart failure or in patients with
uncontrolled hypertension. Resuming ACEi/ARB treatment is recommended within
48h in the postoperative period.
In conclusion, the decision to continue or withhold ACEi/ARB should be individualized, taking into consideration the indications of the drug, the patient hemodynamics and cardiac status, as well as the type of surgery and anesthesia planned.
Thus, a one-size-ts-all approach for perioperative ACEi/ARB management is not
recommended. A summary of the management of patients on antihypertensive medications is presented in Table5.3.
Conclusion
Many areas of controversy remain regarding the optimal perioperative management
of medications such as antiplatelets, anticoagulants, beta blockers, and ACEi/ARBs.
International guidelines are regularly revised and updated to incorporate the most
recent and relevant data. They are a practical and evidence-based framework that is
helpful in guiding the clinician’s decisions and help him navigate through the many
challenges of the high-risk patient.
References
1. Abbott TEF, Pearse RM, Archbold RA, Wragg A, Kam E, Ahmad T, etal. Association between
preoperative pulse pressure and perioperative myocardial injury: an international observational
cohort study of patients undergoing non-cardiac surgery. Br J Anaesth. 2017;119(1):78–86.
5 Managing the Patient on Antiplatelet, Anticoagulation, Beta Blockers…
https://t.me/med1917
2. Venkatesan S, Myles PR, Manning HJ, Mozid AM, Andersson C, Jørgensen ME, etal. Cohort
study of preoperative blood pressure and risk of 30-day mortality after elective non-cardiac
surgery. Br J Anesth. 2017;119(1):65–77.
3. Tryba M. [Epidural regional anesthesia and low molecular heparin: pro]. Anasthesiol
Intensivmed Notfallmed Schmerzther. 1993;28(3):179–81. [German].
4. Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial
blockades in Sweden 1990-1999. Anesthesiology. 2004;101(4):950–9.
5. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia.
Anesth Analg. 1994;79(6):1165–77.
6. Lee LA, Posner KL, Domino KB, Caplan RA, Cheney FW. Injuries associated with
regional anesthesia in the 1980s and 1990s: a closed claims analysis. Anesthesiology.
2004;101(1):143–52.
7. Wiegel M, Gottschaldt U, Hennebach R, Hirschberg T, Reske A.Complications and adverse
effects associated with continuous peripheral nerve blocks in orthopedic patients. Anesth
Analg. 2007;104(6):1578–82.
8. Mariano ER, Loland VJ, Bellars RH, Sandhu NS, Bishop ML, Abrams RA, etal. Ultrasound
guidance versus electrical stimulation for infraclavicular brachial plexus perineural catheter
insertion. J Ultrasound Med. 2009;28(9):1211–8.
9. Bergman BD, Hebl JR, Kent J, Horlocker TT. Neurologic complications of 405 consecutive
continuous axillary catheters. Anesth Analg. 2003;96(1):247–52.
10. Weller RS, Gerancher JC, Crews JC, Wade KL.Extensive retroperitoneal hematoma without
neurologic decit in two patients who underwent lumbar plexus block and were later anticoagulated. Anesthesiology. 2003;98(2):581–5.
11. Bickler P, Brandes J, Lee M, Bozic K, Chesbro B, Claassen J.Bleeding complications from
femoral and sciatic nerve catheters in patients receiving low molecular weight heparin. Anesth
Analg. 2006;103(4):1036–7.
12. Ozturk B, Johnsen SP, Rock ND, Pedersen L, Pedersen AB.Impact of comorbidity on the
association between surgery delay and mortality in hip fracture patients: a Danish nationwide
cohort study. Injury. 2019;50(2):424–31.
13. Quinlan J, Cox F.Acute pain management in patients with drug dependence syndrome. Pain
Rep. 2017;2(4):e611.
14. Hopkins PM. Does regional anaesthesia improve outcome? Br J Anaesth. 2015;115(Suppl
2):ii26–33.
15. Smith LM, Cozowicz C, Uda Y, Memtsoudis SG, Barrington MJ. Neuraxial and combined
neuraxial/general anesthesia compared to general anesthesia for major truncal and lower limb
surgery: a systematic review and meta-analysis. Anesth Analg. 2017;125(6):1931–45.
16. Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a
cochrane systematic review and meta-analysis. Br J Anaesth. 2013;111(5):711–20.
17. Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA, etal. Consensus guidelines
for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118(1):85–113.
18. Hutton M, Brull R, Macfarlane AJR. Regional anaesthesia and outcomes. BJA Educ.
2018;18(2):52–6.
19. Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT.Regional
anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society
of Regional Anesthesia and Pain Medicine evidence-based guidelines (fourth edition). Reg
Anesth Pain Med. 2018;43(3):263–309.
20. Bouma BN, Mosnier LO. Thrombin activatable brinolysis inhibitor (TAFI)—how does
thrombin regulate brinolysis? Ann Med. 2006;38(6):378–88.
21. Rosencher N, Bonnet MP, Sessler DI. Selected new antithrombotic agents and neuraxial anaesthesia for major orthopaedic surgery: management strategies. Anaesthesia.
2007;62(11):1154–60.
22. Hawn MT, Graham LA, Richman JS, Itani KM, Henderson WG, Maddox TM. Risk of
major adverse cardiac events following noncardiac surgery in patients with coronary stents.
JAMA. 2013;310(14):1462–72.
83
Соседние файлы в папке @xirurgi_2025