Perioperative antithrombotic management in joint replacement surgeries

Abstract

Objectives To determine optimal perioperative antithrombotic management for patients with cardiac diseases undergoing joint replacement surgeries. Data sources MEDLINE and PubMed database search up to January 2013. Study selection Those dealing with perioperative antithrombotic management of patients undergoing orthopaedic operations, especially joint replacement, and also those undergoing general surgery. Various combinations of the following key words were used in our search: 'antiplatelet', 'antithrombotic', 'anticoagulant', 'coronary stent', 'perioperative', 'venous thromboembolism', 'cardiovascular', 'surgery', 'orthopaedic', 'knee replacement', 'hip replacement', 'joint replacement', and 'arthroplasty'. Data extraction Literature review, original articles, and best practice guidelines. Data synthesis Patients should be stratified according to their risk of developing arterial thromboembolism in order to decide the most appropriate perioperative antiplatelet or anticoagulant regimen for them. After recent coronary stenting, including bare-metal stents implanted within 6 weeks and drug-eluting stents implanted within 6 months, surgery should be deferred. For venous thromboembolism prophylaxis in patients already on aspirin, the dosage should be adjusted as necessary or additional low-molecular-weight heparin administered. Conclusion The perioperative management of patients with cardiac diseases in receipt of antithrombotic agents is based upon a delicate balance between the perceived risk of arterial thromboembolism and the perceived risk of perioperative bleeding. One must exercise good judgement in deciding the most appropriate perioperative antithrombotic regimen. Venous thromboembolism is also a common problem after joint replacement surgeries. For patients already on aspirin, optimal venous thromboembolism prophylaxis is still being debated.

目的 探討因心臟系統疾病須服食抗血栓藥物而將接受關節置換手術的病人，其手術前後的最佳抗血栓藥物調校方案。 資料來源 於MEDLINE及PubMed資料庫搜索直至2013年1月的文獻。 研究選取 所有與手術前後抗血栓藥物調校方案相關的文獻，包括將接受骨科手術，尤其是關節置換手術的有關病人，以及將接受普通外科手術的有關病人。用以搜索文獻的不同組合的關鍵詞為「抗血小板」 （antiplatelet）、「抗血栓」（antithrombotic）、「抗凝」（anticoagulant）、「冠狀動脈支架」（coronary stent）、「圍手術期」（perioperative）、「靜脈血栓」（venous thromboembolism）、「心血管」（cardiovascular）、「手術」（surgery）、「骨科」（orthopaedic）、「膝關節置換術」 （ k n e e r e p l a c e m e n t ） 、 「 髖 關 節 置 換 術 」（hip replacement）、「關節置換術」（joint replacement）及「關節成形術」（arthroplasty）。 資料選取 文獻回顧、原創論文和常規應用指引。 資料綜合 醫生應按動脈栓塞風險的高低而將病人分類，從而決定手術前後抗血栓藥物最適當的調校方案。於最近曾植入冠狀動脈支架的病人，包括於最近六星期內曾植入裸金屬支架或於最近六個月內曾植入藥物塗層支架的病人，應將手術期押後。至於已經服食亞士匹靈而 有需要作靜脈栓塞預防的病人，醫生可調校亞士匹靈至合適的劑量或可額外處方低分子肝素以作靜脈栓塞預防。 結論 帶有心臟系統疾病須服食抗血栓藥物而將接受關節置換手術的病人，其手術前後的抗血栓藥物調校方案的決定是基於動脈栓塞的風險及手術期間失血風險之間的平衡。醫生應從而決定手術前後的最佳抗血栓藥物調校方案。靜脈栓塞也是關節置換手術後常見的問 題。對於已經服食亞士匹靈病人的最佳預防靜脈栓塞方案，現在還未有定論。