TY - JOUR A1 - Döhler, Ida A1 - Röder, Daniel A1 - Schlesinger, Tobias A1 - Nassen, Christian Alexander A1 - Germer, Christoph-Thomas A1 - Wiegering, Armin A1 - Lock, Johan Friso T1 - Risk-adjusted perioperative bridging anticoagulation reduces bleeding complications without increasing thromboembolic events in general and visceral surgery JF - BMC Anesthesiology N2 - Background Perioperative bridging of oral anticoagulation increases the risk of bleeding complications after elective general and visceral surgery. The aim of this study was to explore, whether an individual risk-adjusted bridging regimen can reduce bleeding events, while still protecting against thromboembolic events. Methods We performed a quality improvement study comparing bridging parameters and postoperative outcomes before (period 1) and after implementation (period 2) of a new risk-adjusted bridging regimen. The primary endpoint of the study was overall incidence of postoperative bleeding complications during 30 days postoperatively. Secondary endpoints were major postoperative bleeding, minor bleeding, thromboembolic events, postoperative red blood cell transfusion, perioperative length-of-stay (LOS) and in-hospital mortality. Results A total of 263 patients during period 1 and 271 patients during period 2 were compared. The included elective operations covered the entire field of general and visceral surgery. The overall incidence of bleeding complications declined from 22.1% during period 1 to 10.3% in period 2 (p < 0.001). This reduction affected both major as well as minor bleeding events (8.4% vs. 4.1%; p = 0.039; 13.7% vs. 6.3%; p = 0.004). The incidence of thromboembolic events remained low (0.8% vs. 1.1%). No changes in mortality or length-of-stay were observed. Conclusion It is important to balance the individual thromboembolic and bleeding risks in perioperative bridging management. The risk adjusted bridging regimen reduces bleeding events in general and visceral surgery while the risk of thromboembolism remains comparably low. KW - low-molecular heparin KW - atrial fibrillation KW - postoperative bleeding KW - thromboembolism KW - anticoagulation KW - bridging Y1 - 2023 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-357305 VL - 23 ER - TY - THES A1 - Borst, Peter T1 - Praktische Aspekte der perioperativen Überbrückung einer oralen Antikoagulation (Bridging) in der Allgemein- und Viszeralchirurgie T1 - Practial aspects of perioperative bridging oral anticoagulation in general- and visceral surgery N2 - Die Anzahl von Patienten mit einer dauerhaften oralen Antikoagulation sowie einer elektiven Operation steigt kontinuierlich. Meist erfolgt die perioperative Umstellung auf ein niedermolekulares Heparin, das sogenannte Bridging. Bisher gibt es keine evidenzbasierte Leitlinie. In der aktuellen Literatur zeigt sich, dass das perioperative Bridging das Risiko einer postoperativen Blutung erhöht. Ziel der Studie war es, das Blutungsrisiko beim Bridging und die Leitlinienadhärenz bei viszeralchirurgischen Eingriffen zu untersuchen. Es handelt sich um eine retrospektive, monozentrische Studie. Die Patientenselektion erfolgte mit dem Krankenhausinformationssystem für den Zeitraum 01. Januar 2011 bis 31. Dezember 2014. Eingeschlossen wurden Patienten mit einer dauerhaften oralen Antikoagulation, verfügbaren Patientenakte und einem elektiven operativen Eingriff. Ausschlusskriterien waren Notfalleingriffe, bariatrische Eingriffe und Gefäßoperationen. Erfasst wurden Komorbiditäten, die perioperative Dosierung und Pausierung des Bridging sowie postoperative Komplikationen. Insgesamt konnten 263 Fälle ausgewertet werden, wobei in 58 Fällen postoperative Blutungen auftraten (22,1%; 30 subkutane Hämatome, 17 lokale Blutungen, 5 Hämaskos, 3 peranale Blutungen, 3 Sonstige), in 68 Fällen erfolgten Transfusionen (26%) und in 40 Fällen Revisionsoperationen (15%). Das Risiko für Blutungen war erhöht beim Bridging in einer therapeutischen Dosierung (2x1mg/kgEnoxaparin;N=51/189,27%) im Vergleich zur halb- therapeutischen (1x1mg/kg; N=3/26, 12%) und prophylaktischen Dosierung (1x40mg; N=4/49, 8%; P=0,007). Thromboembolische Ereignisse traten bei 2 Patienten auf (0,8%; Apoplex, Lungenembolie). Eine falsche Risikobewertung führte bei 28 Patienten (11%) zu einem nicht indizierten therapeutischen Bridging, wobei hier 7 Blutungen auftraten. Darüber hinaus war die perioperative Pausierung des Bridging bei der Mehrzahl der Fälle zu kurz. Die präoperative Pausierung korrelierte mit dem Risiko für Bluttransfusionen (P=0,028). Die Leitlinie wurde bei 96% der Patienten nicht befolgt. Patienten mit einem Bridging in einer therapeutischen Dosierung unterliegen einem hohen Risiko für postoperative schwere Blutungskomplikationen. In der Praxis wird die Indikation zum Bridging oftmals nicht ausreichend differenziert und die perioperative Pausierung nicht eingehalten. Die Indikation zum perioperativen Bridging muss mit Hilfe einer individuellen präoperativen Risikostratifizierung für das perioperative Blutungs- und Thromboembolierisiko gestellt werden. N2 - Increasing numbers of patients receiving oral anticoagulants are undergoing elective surgery. Bridging therapy is commonly thought to reduce the risk of postoperative bleeding and thromboembolic events. Low molecular weight heparin (LMWH) is frequently applied as bridging therapy during perioperative interruption of anticoagulation. The aim of this study was to explore the postoperative risk of bleeding and thromboembolic complications of patients receiving surgery under bridging anticoagulation. We performed a monocentric retrospective study over the period 2011-2014 using the clinical data system. Inclusion criteria were elective surgery, oral anticoagulation and full available patient records. Exclusion criteria emergency surgery, bariatric surgery and vascular surgery. Acquired data were comorbidity, perioperative enoxaparin dosage and pause., postoperative bleeding and thromboembolic events. The statistical analysis was performed with IBM SPSS Statistics 22. The sample of the study consisted of 263 patients. Postoperative overall bleeding events occurred in 58 patients (22,1%), postoperative need of blood cell transfusion in 68 patients (26%) and revision surgery in 40 patients (15%). Patients undergoing bridging in full therapeutic dosage enoxaparin (2x1mg/kg; n=51/189, 27%) had a higher risk for postoperative bleeding compared to half therapeutic dosage (1x1mg/kg; n=3/26, 12%) and prophylactic dosages of enoxaparin (1x40mg/kg; n=4/49, 8%; P=0,007). Thromboembolic events occurred only in two patients (0,8%; Stroke, Pulmonary Embolism). Bridging by clinical protocol (n=11/263; 4%) led to an overall bleeding risk of 45,5% (n=5/11), whereas not following protocol (n=252/263; 96%) resulted in 21% (n=53/252; P=0,056). Perioperative bridging anticoagulation, especially full-therapeutic dose LMWH, markedly increases the risk of postoperative bleeding complications in general and visceral surgery. Surgeons should carefully consider the practice of routine bridging. KW - bridging KW - Bridging KW - orale Antikoagulation KW - Viszeralchirurgie KW - postoperative Blutung Y1 - 2021 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-221024 ER - TY - JOUR A1 - Lock, J. F. A1 - Ungeheuer, L. A1 - Borst, P. A1 - Swol, J. A1 - Löb, S. A1 - Brede, E. M. A1 - Röder, D. A1 - Lengenfelder, B. A1 - Sauer, K. A1 - Gremer, C. - T. T1 - Markedly increased risk of postoperative bleeding complications during perioperative bridging anticoagulation in general and visceral surgery JF - Perioperative Medicine N2 - Background Increasing numbers of patients receiving oral anticoagulants are undergoing elective surgery. Low molecular weight heparin (LMWH) is frequently applied as bridging therapy during perioperative interruption of anticoagulation. The aim of this study was to explore the postoperative bleeding risk of patients receiving surgery under bridging anticoagulation. Methods We performed a monocentric retrospective two-arm matched cohort study. Patients that received perioperative bridging anticoagulation were compared to a matched control group with identical surgical procedure, age, and sex. Emergency and vascular operations were excluded. The primary endpoint was the incidence of major postoperative bleeding. Secondary endpoints were minor postoperative bleeding, thromboembolic events, length of stay, and in-hospital mortality. Multivariate analysis explored risk factors of major postoperative bleeding. Results A total of 263 patients in each study arm were analyzed. The patient cohort included the entire field of general and visceral surgery including a large proportion of major oncological resections. Bridging anticoagulation increased the postoperative incidence of major bleeding events (8% vs. 1%; p < 0.001) as well as minor bleeding events (14% vs. 5%; p < 0.001). Thromboembolic events were equally rare in both groups (1% vs. 2%; p = 0.45). No effect on mortality was observed (1.5% vs. 1.9%). Independent risk factors of major postoperative bleeding were full-therapeutic dose of LMWH, renal insufficiency, and the procedure-specific bleeding risk. Conclusion Perioperative bridging anticoagulation, especially full-therapeutic dose LMWH, markedly increases the risk of postoperative bleeding complications in general and visceral surgery. Surgeons should carefully consider the practice of routine bridging. KW - low molecular heparin KW - atrial fibrillation KW - postoperative bleeding KW - thromboembolism KW - anticoagulation KW - bridging KW - antithrombotic therapy KW - warfarin interruption KW - oral anticoagulants KW - management Y1 - 2020 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-230690 VL - 9 ER -