口服抗凝血药物患者严重出血的管理策略
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Management of Severe Bleeding in Patients Treated with Direct Oral Anticoagulants
背景
口服凝血酶原复合物浓缩物和血浆抗凝剂在患者出血管理中的作用仍然存在争议。此目的为探讨直接口服抗凝药物患者严重出血的管理策略及其结局。
方 法
本研究为前瞻性队列研究，共纳入2013年6月至2015年11月服用过达比加群、利伐沙班或阿哌沙等抗凝药物的严重出血住院病人。
结 果
共纳入732名患者，胃肠道出血患者为37%，颅内出血患者占24%。61%的患者肌酐清除率低于60ml∕min。在62%的直接口服抗凝药物的患者中，9.2%的患者血浆中药物浓低于50ng∕ml，6.6%的患者高于400ng∕ml；38%的患者通过其他方式给予活化或为活化的凝血酶原复合物浓缩物。第30天的死亡率为14%（95%CI:11～16）。
结 论
口服抗凝血药物患者严重出血的管理策略稍显复杂。出血部位因口服抗凝血酶原复合物的血浆浓度差异而有所不同，且死亡率依出血部位而定。
原始文献摘要
Albaladejo P, Samama C M, Sié P, et al. Management of Severe Bleeding in Patients Treated with Direct Oral Anticoagulants: An Observational Registry Analysis[J]. Anesthesiology, 2017.
Background: The use of prothrombin complex concentrates and the role of plasma concentration of anticoagulants in the management of bleeding in patients treated with direct oral anticoagulants are still debated. Our aim was to describe management
strategies and outcomes of severe bleeding events in patients treated with direct oral anticoagulants.
Methods: We performed a prospective cohort study of 732 patients treated with dabigatran, rivaroxaban, or apixaban hospitalized for severe bleeding, included prospectively in the registry from June 2013 to November 2015.
Results: Bleeding was gastrointestinal or intracranial in 37% (212 of 732) and 24% (141 of 732) of the cases, respectively.Creatinine clearance was lower than 60 ml/min in 61% (449 of 732) of the cases. The plasma concentration of direct oral anticoagulants
was determined in 62% (452 of 732) of the cases and was lower than 50 ng/ml or higher than 400 ng/ml in 9.2%(41 of 452) and in 6.6% (30 of 452) of the cases, respectively. Activated or nonactivated prothrombin complex concentrateswere administered in 38% of the cases (281 of 732). Mortality by day 30 was 14% (95% CI, 11 to 16).
Conclusions: Management of severe bleeding in patients treated with direct oral anticoagulants appears to be complex. The use of prothrombin complex concentrates differs depending on bleeding sites and direct oral anticoagulant plasma concentrations.
Mortality differs according to bleeding sites and was similar to previous estimates.
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