应用新型抗凝药物患者的围手术期管理

Perioperative management of patients received new oral anticoagulants

背景心房纤颤（房颤）是临床中最常见的心律失常。新型口服抗凝药物（neworalanticoagulant，NOAC）因其起效迅速、半衰期短、食物药物相互作用少、出血并发症少、无需频繁监测国际标准化比值（internationalnormalizedratio，INR）等优点，逐渐成为房颤患者的抗凝一线用药。目的综述围手术期应用NOAC的管理。内容临床应用的NOAC包括达比加群、利伐沙班、阿哌沙班和依杜沙班等，这些药物与华法林的临床效果相同，但是其出血和栓塞的风险显著降低。在围手术期管理中，NOAC的选择主要取决于患者的用药史、手术和麻醉的类型、出血倾向和栓塞风险。在NOAC使用期间，对其凝血功能和药代动力学进行了精确检验。至今为止，达比加群是NOAC中唯一具有特异性拮抗剂的药物（idarucizumab）；对于其他NOAC药物，除了通过新鲜冰冻血浆稀释血液和使用凝血酶原复合物，没有有效的拮抗剂。趋向围手术期NOAC药物管理问题需要得到进一步的研究：①缺乏标准化、灵敏和简单的检测NOAC血药浓度的方法；②缺乏有效的特异性拮抗剂。

Background Atrial fibrillation （AF） is the most common cardiac arrhythmia in clinical practice. New oral anticoagulants （NOAC） have become the first line anticoagulants for patients with atrial fibrillation because of its rapid onset, short half-life, less food-drug interactions, less bleeding complications, and relatively stable international normalized ratio（INR）. Objective To review the management of NOAC in perioperative period. Content NOAC for clinical use include dabigatran, rivaroxaban, apixaban, and edoxaban, etc. These drugs have similar effectiveness as warfarin, but significantly lower incidence of hemorrhage and embolism. In perioperative management, NOAC may be selected according to medical history, types of operation and anesthesia, and propensity of bleeding and blood congestion in patients. During the application of NOAC, the coagulation function and pharmacokinetics of the drugs should be assayed with appropriate methods. Up till now, dabigatran is the only currently available NOAC that has specific antidote, idarucizumab. Except for dilution with freshly frozen plasma and administration of prothrombin complex concentrates, no available drugs can antagonize the effects of other NOAC. Trend Further investigations are demanding to overcome two he major challenges for clinical management of perioperative NOAC： lacks of standard, sensitive, and easy-to-use methods to measure the concentrations of NOAC. absence of ootent specific antagonists for individual NOAC.