手術或侵入性處置前後的抗血小板藥品及抗凝血藥品（統稱抗血栓藥品）之因應策略為重要的用藥安全議題，不適當停用抗血栓藥品可能增加病人栓塞風險或出血風險。術前應同時評估術式的出血風險、停藥的栓塞風險及其他個人風險因子（如年齡、肝腎功能、共病症、併用藥品等），並與開方醫師、術式相關醫師、麻醉醫師、藥師以及病人取得共識以擬訂個別化的停藥策略。除此之外，抗血栓藥品需依照藥物動力學特性及病人因素（如international normalized ratio 數值、腎功能等）決定停用天數。而高栓塞風險病人可考慮在停用抗血栓藥品時使用銜接治療，緊急手術亦可考慮使用反轉劑，術後的復藥時機也是重要課題。因此，完整的停藥策略應評估：(1) 是否停用抗血栓藥品、(2) 何時停用抗血栓藥品、(3) 是否使用銜接治療、(4) 是否使用反轉劑、(5) 何時復藥。本文回顧歐美各大學會指引，整理出血風險與栓塞風險之評估建議、進行常規手術前後抗血栓藥品之使用建議，以及進行緊急手術前抗血栓藥品之使用建議。期許藉由本文協助國內醫療團隊建立手術及侵入性處置前後使用抗血栓藥品的作業流程規範，以提升病人用藥安全。

 

The use of perioperative and periprocedural antiplatelet and anticoagulant therapies (i.e., antithrombotic therapy) is a topic of critical concern. Inappropriate discontinuation of antithrombotic therapy may increase the risks of ischemic and bleeding events. Before an operation, clinical staff should evaluate the risk of surgical bleeding, the ischemic risk posed by drug discontinuation, and other personal risks (e.g., age, liver and kidney function, comorbidities, and concomitant medications) and establish an individualized perioperative and periprocedural antithrombotic strategy. In addition, antithrombotic agents should be discontinued in accordance with their pharmacokinetics and with patient-related factors (e.g., international normalized ratio and renal function). Clinical staff should consider the use of bridging therapy in patients at high ischemic risk when discontinuing antithrombotic therapy. Reversal agents can also be considered for emergency surgery. In addition, the timing of antithrombotic therapy resumption after an operation is crucial. Therefore, a complete perioperative and periprocedural antithrombotic therapy strategy should include the following details: (1) whether to stop antithrombotic therapy; (2) when to stop antithrombotic therapy; (3) whether to use bridging therapy; (4) whether to use a reversal agent; and (5) when to resume antithrombotic therapy. This article reviews the guidelines of major European and American medical societies. It summarizes the recommendations for assessing the risks of bleeding and ischemic events, antithrombotic therapy before and after routine surgery, and antithrombotic therapy before emergency surgery. This article provides evidence with which medical teams can establish perioperative and periprocedural management strategies for patients receiving antithrombotic agents to improve medication safety. 

 

 

Submitted for publication: 2022.10.20; Accepted for publication: 2023.4.25