The Postoperative Dip in Peroperative Anticoagulation

O Kluft; W Stortenbeek; S. I de Vries; J Wieberdink

doi:10.1055/s-0038-1656226

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 1965; 13(01): 218-234
DOI: 10.1055/s-0038-1656226

Originalarbeiten — Original Articles — Travaux Originaux

Schattauer GmbH Schattauer

The Postoperative Dip in Peroperative Anticoagulation

Authors

O Kluft

¹University of Amsterdam, Surgical Department (Head: Prof. Dr. I. Boerema), and from the Laboratory of Blood transfusion and Haematology of the Wilhelmina Gasthuis (Head: S. I. de Vries, M. D.)
W Stortenbeek

¹University of Amsterdam, Surgical Department (Head: Prof. Dr. I. Boerema), and from the Laboratory of Blood transfusion and Haematology of the Wilhelmina Gasthuis (Head: S. I. de Vries, M. D.)
S. I de Vries

¹University of Amsterdam, Surgical Department (Head: Prof. Dr. I. Boerema), and from the Laboratory of Blood transfusion and Haematology of the Wilhelmina Gasthuis (Head: S. I. de Vries, M. D.)
J Wieberdink

¹University of Amsterdam, Surgical Department (Head: Prof. Dr. I. Boerema), and from the Laboratory of Blood transfusion and Haematology of the Wilhelmina Gasthuis (Head: S. I. de Vries, M. D.)

Abstract

Summary and Conclusions

1. A postoperative dip as measured by the Thrombotest or prothrombin time occurs after pecoperative anticoagulation on a therapeutic level with coumarin derivatives.

2. This dip usually occurs on the first postoperative day.

3. Estimations of the coagulation factors influenced by vitamin K1 revealed values which were near or under the critical bleeding level.

4. It was found that a more or less impaired liver function after the operation was unable to counteract the increased postoperative consumption of coagulation factors.

5. In all cases of perioperative anticoagulation three principles should be kept in mind in order to circumvent either bleeding or thrombosis.

a) recognition of the existence of a postoperative dip.

b) frequent postoperative estimations of the Thrombotest or the prothrombin time.

c) correction of the anticoagulation to the therapeutic level by means of small doses of vitamin K1 and appropriate laboratory control.

6. The danger of peroperative anticoagulation (haemorrhage) is mainly due to the postoperative dip and can, therefore, largely be prevented.

Full Text

References

References
1 Alexander B. A guide to anticoagulant therapy. Circulation 24: 123 1961;
2 Astrup T. The haemostatic balance. Thrombos. Diathes. haemorrh. (Stuttg.) 2: 347 1958;
3 Behrman B. J, Wright I. S. Dental surgery during continuous anticoagulant therapy. J. Amer. med. Ass. 175: 483 1961;
4 Bergquist G. Changes in blood in connection with thromboembolism. An investigation regarding operation and delivery. Acta chir. scand. 92 (Suppl. 101) 119 1945;
5 Bertrand I, Quivy D, Debeyre J, Braillard S. Le test de Lenggenhager dans le diagnostic des thromboses. C. R. Soc. Biol. 140: 344 1946;
6 Carey L. C, Williams R. D. Comparative effects of dicoumarol, tromexan and heparin on thrombus propagation. Ann. Surg. 152: 919 1960;
7 Chen T. I, Tsai D. The mechanism of hemostasis in peripheral vessels. J. Physiol. 107: 280 1948;
8 De Takats G. Heparin tolerance. A test of the clotting mechanism. Surg. Gynec. Obstet. 77: 31 1943;
9 Dick W, Matis P, Mayer W. Results of alternating anticoagulant prophylaxis in surgery. Thrombos. Diathes. haemorrh. (Stuttg.) 3: 11 1959;
10 Dinon L. R, Van der Veer J. B. Recurrent myocardial infarction after cessation of anticoagulant therapy. Amer. Heart J. 60: 6 1960;
11 Eckmann L. Eingriffe bei präoperativ begonnener Anticoagulantienbehandlung. Langen-becks Arch. klin. Chir. 298: 560 1961;
12 Egeberg O. Changes in the coagulation system following major surgical operations. Acta med. scand. 171: 679 1962;
13 Gammelgaard A. Anticoagulant prophylaxis in vascular surgery. Experimental studies in small vessel replacement. Acta chir. scand. 121: 103 1961;
14 Gormsen J. Heparin resistance determined by the heparin tolerance test in patients treated with phenylindanedione before, during and after operation. Acta chir. scand. 121: 367 1961;
15 Gormsen J, Andersen A, Gammelgaard A. Prostatectomy during anticoagulant therapy. Acta chir. scand. 120: 380 1961;
16 Gormsen J. Operative and postoperative changes in blood coagulation. Acta chir. scand. 121: 373 1961;
17 Gormsen J, Haxholdt B. Fl. The heparin tolerance test and thrombo embolic incidence in surgery. Acta chir. scand. 120: 121 1960;
18 Jordan F. L. J. Een jaar thrombose dienst. Ned. T. Geneesk. 94: 2610 1950;
19 Kettenborg H. K, Japikse J. E. De behandeling van thrombo embolische processen met de combinatie van héparine en coumarine preparaten. Ned. T. Geneesk. 105: 355 1961;
20 Kettenborg H. K. Bloedstolling en thrombosedreiging, (Blood coagulation and prethrombotic state). Thesis, Amsterdam, ed. by Holdert and Co, p. 136, 1956
21 Kettenborg H. K, De Vries S. I, Van der Pol E. T. Modifications in the behaviour of coagulation factors during storage of blood and its importance for blood transfusions. Rev. belg. Path. 24: 136 1955;
22 Keyes J. W. et al. Survival rates after acute myocardial infarction with long term anticoagulant therapy. Circulation 14: 254 1956;
23 Kluft O, Wieberdink J, De Vries S. I. Intraveneuze toediening van coumarine derivaten. Ervaringen met Warfarine-Natrium. Ned. T. Geneesk. 107: 435 1963;
24 Lenggenhager K. Über die Entstehung, Erkennung und Vermeidung der postoperativen Fernthrombose. P. 31, p. 37. Thieme, Leipzig 1941
25 Lindgren S, Wilander O. The use of heparin in vascular surgery. Acta med. scand. 107: 148 1941;
26 Littman J. K, Brodman H. R. Surgery in the presence of the therapeutic effect of dicumarol. Surg. Gynec. Obstet. 101: 709 1955;
27 McGlure R. D, Harkins H. N. Recent advances in the treatment of peripheral arterial embolism. Surgery 14: 747 1943;
28 Meyne N. G. Een experimenteel onderzoek over endotheelgroei bij nylon vaatprothesen. Thesis, Amsterdam, ed. De Hoop, Amsterdam, 1957
29 Mullertz S, Storm O. Anticoagulant therapy with dicumarol maintained during major surgery. Circulation 10: 213 1954;
30 Murray G. D. W. Heparin in thrombosis and embolism. Brit. J. Surg. 27: 567 1940;
31 O’Reilly R. A, Aggeler P. M, Leong L. S. Studies on the coumarin anticoagulant drugs: the pharmacodynamics of warfarin in man. J. Clin. Invest 42: 1542 1963;
32 Poller L. Coagulation and thrombosis. Clin. Sci. 15: 55 1956;
33 Roberts H. J. Control of bleeding after dental extraction during anticoagulant therapy. J. Amer. med. Ass. 175: 962 1961;
34 Schmidt W. J. H. Diagnostiek der post-opérâtieve thrombose. Thesis, Amsterdam, ed. Uit-gevers My C. Deiwel, Den Haag, p. 126, 1953
35 Shumacker H. B, Abramson D. I, Lampert H. H. The use of anticoagulants in the surgery of aneurysms and arterio venous fistulas with particular reference to dicumarol. Surgery 22: 910 1947;
36 Scott H. W, Williams J. M. Multiple arterial emboli. Three successful embolectomies in a case of bacterial endocarditis. Arch. Surg. 58: 28 1949;
37 Sevitt S, Gallagher N. G. Prevention of venous thrombosis and pulmonary embolism in injured patients. A trial of anticoagulant prophylaxis with phenindione in middle aged and elderly patients with fractured necks of the femur. Lancet II: 981 1959;
38 Sharnoff J. G. Increased pulmonary megakaryocytes. Probable role in postoperative thromboembolism. J. Amer. med. Ass. 169: 688 1959;
39 Sterling Nichol E. et al. Long term anticoagulant therapy in coronary atherosclerosis. Amer. Heart J. 55: 143 1958;
40 Storm O, Hansen A. T. Mitral commissurotomy performed during anticoagulant prophylaxis with dicumarol. Circulation 12: 981 1955;
41 Storm O, Gammelgaard P. A. Antithrombotic treatment in vascular surgery. Acta chir. scand. 715/460 1957
42 Storm O. Prä- und peroperative Prophylaxe der Thrombose. Thrombos. Diathes. haemorrh. (Stuttg.), Suppl. Vol. V, Symposion Hamburg, p. 90, 1960
43 Storm O. Anticoagulant protection in surgery. Thrombos. Diathes. haemorrh. (Stuttg.) 2: 484 1958;
44 Thies H. A. Postoperative Blutgerinnungsstörungen im Zusammenhang mit Transfusionen und Infusionen. Zbl. Chir. 86: 1211 1961;
45 Tocantins L. M. The mechanism of hemostasis. Ann. Surg. 125: 292 1947;
46 Tsitouris G, Bellet S, Eilberg R, Feinberg L, Sandberg H. Effects of major surgery on plasmin-plasminogen inhibitors. Arch, intern. Med. 108: 208 1961;
47 Warren R, Belko J. S. Deficiency of plasma prothrombin conversion accelerators in the postoperative state with a description of a simple method of assay. Blood 6: 544 1951;
48 Wright I. S. A bear by the tail? The discontinuance of anticoagulant therapy. Dis. Chest 40: 454 1961;
49 Wright H. P, Kubik M. M, Hayden M. Recanalization of thrombosed arteries under anticoagulant therapy. Brit. med. J. I: 1021 1953;