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Perioperative Management of Patients Treated with Antithrombotics in Oral Surgery

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Perioperative Management of Patients Treated with Antithrombotics in Oral Surgery SFCO/Perioperative management of patients treated with antithrombotic agents in oral surgery/Rationale/July 2015 SOCIÉTÉ FRANÇAISE DE CHIRURGIE ORALE [FRENCH SOCIETY OF ORAL SURGERY] IN COLLABORATION WITH THE SOCIÉTÉ FRANÇAISE DE CARDIOLOGIE [FRENCH SOCIETY OF CARDIOLOGY] AND THE PERIOPERATIVE HEMOSTASIS INTEREST GROUP Space Perioperative management of patients treated with antithrombotics in oral surgery. RATIONALE July 2015 P a g e 1 | 107 SFCO/Perioperative management of patients treated with antithrombotic agents in oral surgery/Rationale/July 2015 Abbreviations ACS Acute coronary syndrome(s) ADP Adenosine diphosphate Afib Atrial Fibrillation AHT Arterial hypertension Anaes Agence nationale d’accréditation et d’évaluation en santé [National Agency for Accreditation and Health Care Evaluation] APA Antiplatelet agent(s) aPTT Activated partial thromboplastin time ASA Aspirin BDMP Blood derived medicinal products BMI Body mass index BT Bleeding Time cAMP Cyclic adenosine monophosphate COX-1 Cyclooxygenase 1 CVA Cerebral vascular accident DIC Disseminated intravascular coagulation DOA Direct oral anticoagulant(s) DVT Deep vein thrombosis GEHT Study Group on Hemostasis and Thrombosis (groupe d’étude sur l’hémostase et la thrombose) GIHP Hemostasis and Thrombosis Interest Group (groupe d’intérêt sur l’hémostase et la thrombose) HAS Haute autorité de santé [French Authority for Health] HIT Heparin-induced thrombocytopenia IANB Inferior alveolar nerve block INR International normalized ratio IV Intravenous LMWH Low-molecular-weight heparin(s) MA Marketing Authorization MI Myocardial infarction minC minimum or residual concentration NABM Classification of Biomedical Procedures (nomenclature des actes en biologie médicale) NSAIDs Non-steroidal anti-inflammatory drugs NSTEMI Non-ST Segment Elevation Myocardial Infarction PAD Peripheral obstructive artery disease PC Platelet count PCC Prothrombin complex concentrate PCI Percutaneous Coronary Intervention PE Pulmonary embolism PMSI Information Systems Medicalization Program (programme de médicalisation des systèmes d’information) PT Prothrombin Time SC Subcutaneous SE Systemic embolism SMD Sterile medical device STEMI ST Segment Elevation Myocardial Infarction SVT Superficial Vein Thrombosis THR Total Hip Replacement TIA Transient Ischemic Attack(s) TKR Total Knee Replacement t-PA tissue Plasminogen Activator TXA2 Thromboxane A2 UFH Unfractionated heparin(s) VKA Vitamin K antagonists or antivitamin K VTE Venous thromboembolism P a g e 2 | 107 SFCO/Perioperative management of patients treated with antithrombotic agents in oral surgery/Rationale/July 2015 Overview I. METHODOLOGY 1. Working method for the preparation of recommendations ............................ 7 2. Literature search and selection of documents ................................................ 7 II. RATIONALE 1. Perioperative management of patients treated with antithrombotics in oral surgery (General Information). ............................................................................ 15 1.1 Balancing risk in the surgical setting ...................................................................................... 15 1.2 Preoperative assessment of the risk of surgical bleeding ..................................................... 16 1.2.1 Taking medical history and clinical examination ....................................................................... 16 1.2.1.1 Hemostasis disorder(s) related to an associated pathology ....................................................................................... 16 1.2.1.2 Patient adherence to his (her) antithrombotic therapy ................................................................................................ 16 1.2.1.3 Type of surgical procedure ........................................................................................................................................... 17 1.2.1.4 Hemorrhagic risk factors that could increase the risk of surgical bleeding. ............................................................... 18 1.2.2. From laboratory examination(s) ............................................................................................... 19 1.3 Choice of the management of structure: general practice or in a hospital? ......................... 19 1.4 Local hemostasis ...................................................................................................................... 20 1.4.1 Surgical hemostatics ................................................................................................................ 20 1.4.1.1 Surgical hemostatics without specific action on the events that occur during hemostasis. ...................................... 21 1.4.1.2 Surgical hemostatics with specific action on the events that occur during hemostasis. ........................................... 21 1.4.2 Tranexamic acid ....................................................................................................................... 21 1.5.1 Postoperative monitoring and tips .......................................................................................... 22 1.5.2 Curative treatment of bleeding complications ........................................................................ 22 2. Specificities of the management of patients treated with antiplatelet agents(s) ................................................................................................................................ 24 2.1 The issues ................................................................................................................................. 24 2.2 Antiplatelet agents .................................................................................................................... 25 2.2.1 Conventional antiplatelet agents............................................................................................... 25 2.2.2.1 Aspirin............................................................................................................................................................................ 25 2.2.2.2 Dipyridamole ................................................................................................................................................................. 26 2.2.2.3 Ticlopidine ..................................................................................................................................................................... 26 2.2.2.4 Clopidogrel .................................................................................................................................................................... 26 2.2.2 Novel antiplatelet agents .......................................................................................................... 27 2.2.2.1 Prasugrel ....................................................................................................................................................................... 28 2.2.2.2 Ticagrelor ...................................................................................................................................................................... 28 2.3 Discontinuation or maintenance of treatment with antiplatelet agents? ............................... 29 2.4 What biological test can be used to evaluate the risk of surgical bleeding in patients on an antiplatelet agent? ................................................................................................................... 31 2.5 Which local hemostasis should be performed to control the risk of surgical bleeding? ..... 31 P a g e 3 | 107 SFCO/Perioperative management of patients treated with antithrombotic agents in oral surgery/Rationale/July 2015 2.6 Curative treatment of bleeding complications ........................................................................ 32 3. Specificities of the management of patients treated with antivitamin K .......... 32 3.1 The issues ................................................................................................................................. 32 3.2 Antivitamin K 34 3.2.1 Acenocoumarol ........................................................................................................................ 34 3.2.2 Warfarin ................................................................................................................................... 35 3.2.3 Fluindione ................................................................................................................................ 35 3.3 Discontinuation or maintenance of therapy with VKA? ......................................................... 35 3.3.1 Local anesthesia (LA) and locoregional anesthesia (LRA). ....................................................... 35 3.3.2 Dento-alveolar surgery ............................................................................................................. 36 3.3.2.1 Dental extraction(s) ....................................................................................................................................................... 36 3.3.2.2 Dental implant(s) ........................................................................................................................................................... 37 3.3.3 Surgery with a high risk of bleeding .......................................................................................... 37 3.3.3.1 Patients at low risk of thrombosis ...............................................................................................................................
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