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Mga Pampapayat ng Dugo Bago ang Operasyon

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How anticoagulants and antiplatelets work, and why the timing of stopping each before surgery differs — platelet turnover, half-lives and clot risk.

Illustrasyon ng isang blood clot — mga red cells na nakakulong sa isang mesh ng fibrin threads sa paligid ng isang klump ng platelets.
Ang daan ay mga platelet na magkakadikit at pinatitibay ng isang mahabang hila ng fibrin — ang proseso na layunin ng mga blood thinner na pigilan. Kieran Hirpara 4.0

Ang pahinang ito ay isinalin ng makina at hindi pa nasusuri ng isang doktor. Ang bersyong Ingles ang siyang opisyal.

Ang "blood thinner" ay tumutukoy sa dalawang pamilya ng gamot na gumagana sa ganap na magkaibang paraan, at ang pagkakaiba na ito ang eksaktong dahilan kung bakit may mga kailangang itigil isang linggo bago ang operasyon habang ang iba ay nangangailangan lamang ng isang o dalawang araw. Ang pagkakaalam kung alin sa mga ito ang iyong kinakain, at kung paano ito talaga gumagana, ay nagpapatunay na ang mga instruksyong ibinibigay sa iyo ay hindi na kasing misteryoso.

Unang-unan, paano talaga bumubuo ng dugo?

Upang maunawaan ang iba't ibang gamot na nagpapapayat ng dugo, makakatulong ang pag-unawa kung paano normal na sarado ng iyong dugo ang isang tagas, dahil bawat gamot ay humahadlang sa iba't ibang hakbang.

Kapag putol o nasira ang isang ugat ng dugo, pinipigilan ng iyong katawan ito sa dalawang yugto:

  1. Ang mga platelet ang nagpupuno sa puwang: ang mabilis na unang tumutugon. Ang mga platelet ay maliliit na piraso ng selula na bumabagsak sa dugo at walang ginagawa hangga't hindi kailangan. Sa sandaling makita nila ang nasirang dingding ng ugat, nagiging malagkit sila, nagtutulungan sa sugat at bumubuo ng magkakadikit na grupo, na bumubuo ng malambot, pansamantalang plug sa loob ng ilang segundo o minuto. Isipin ito bilang emergency patch ng katawan.

  2. Ang clotting cascade ang nagpapatibay sa plug. Ang plug na platelet ay mahina kung mag-isa. Upang suportahan ito, pinapatakbo ng dugo ang isang serye ng reaksyon na tinatawag na clotting cascade, isang serye ng mga protina na tinatawag na clotting factors (karamihan ay ginawa ng atay, at ilang sa kanila ay nangangailangan ng vitamin K) na nagpapagana sa isa't isa sa sunod-sunod na paraan, tulad ng isang hanay ng domino. Natatapos ang cascade sa pagpapalipat ng isang protina na tinatawag na fibrinogen patungo sa fibrin, isang mesh ng manipot na hibla na dumadaan sa plug na platelet at nakakabit dito sa isang matibay, matatag na clot.

Kaya ang isang tapos na clot ay tunay na mga platelet na hawak ng isang fibrin mesh. Kapag nakapag-sara ito ng sugat, ito ang gusto mo; ngunit ang parehong proseso na nangyayari nang hindi gustong-gusto sa loob ng isang arterya o ugat ng dugo ay nagdudulot ng heart attack, stroke o DVT. Ito ang layunin ng mga gamot na nagpapapayat ng dugo na pigilan.

Narito ang susi sa lahat ng nabanggit sa ibaba: ang dalawang pamilya ng gamot na nagpapapayat ng dugo ay humahadlang sa iba't ibang yugto. Ang mga gamot na antiplatelet ay humihina sa unang hakbang (ang mga platelet); ang mga gamot na anticoagulant ay humahadlang sa pangalawa (ang clotting- factor cascade). Ang pagkakaibang ito lamang ang nagpapaliwanag kung bakit magkaiba ang timing bago ang operasyon, dahil ang "pagbawi" ng isang platelet ay hindi katulad ng "pagbawi" ng isang clotting factor.

Mga gamot na antiplatelet

(aspirin, clopidogrel/Plavix, ticagrelor/Brilinta, prasugrel/Effient)

Pinipigilan nito ang mga maliliit na selula ng dugo na tinatawag na platelets na magdikit-dikit upang simulan ang pagbuo ng dugo (clot).

  • Ang aspirin at clopidogrel (kasama ang prasugrel) ay gumagana nang irreversible: kapag dumating na ang gamot sa isang platelet, patay na o hindi na gumagana ang platelet na iyon hanggang sa dulo ng buhay nito. Hindi na ito maibabalik ng iyong katawan. Ang tanging paraan upang muling makabalik sa normal na pagkakadugo ay sa pamamagitan ng paggawa ng mga bagong platelet, at ang platelets ay namumuhay lamang ng mga 7–10 araw, kung saan humigit-kumulang 10% ang napapalitan bawat araw. Kaya pagkatapos mong itigil, kailangan ng mga 5–7 araw upang makabuo ng sapat na bagong, gumagawang platelets para sa ligtas na operasyon. Ito ang dahilan kung bakit karaniwang itinutigil ang mga itong mga isang linggo bago ang operasyon.
  • Ang ticagrelor ay reversible; pinapayagan nitong lumaya ang platelet imbes na permanenteng siraan ito, kaya mas mabilis itong malilinis, ngunit nangangailangan pa rin ng ilang araw.
  • Karaniwang pinapanatili ang aspirin para sa mga operasyon na may mababang panganib ng pagdurugo, o kapag ito ay nagpoprotekta sa isang heart stent, dahil ang maliit na panganib ng pagdurugo ay mas malaki kaysa sa panganib ng pagkakadugo. Ang iyong surgeon ang magdedesisyon.

Mga Antikoagulant

Gumagana ang mga ito sa mas malalim na bahagi ng chain ng pagkakadugo, sa mga factor ng pagkakadugo sa dugo kaysa sa mga platelet.

Warfarin (Coumadin, Marevan). Pinipigilan ng Warfarin ang iyong atay na gumawa ng ilang vitamin-K-dependent na factor ng pagkakadugo. Hindi nito tinatanggal ang mga factor na nasa daloy na; kailangan lang silang maubos at malinis nang natural, na tumatagal ng humigit-kumulang 5 araw. Ito ang dahilan kung bakit karaniwang itinatigil ang warfarin humigit-kumulang 5 araw bago ang operasyon at sinusuri ang isang blood test (ang INR) upang kumpirmahin na bumalik sa normal ang iyong dugo. Kung nasa mataas na risk ka ng pagkakadugo sa loob ng gap na iyon, maaari kang "bridged" gamit ang short-acting na heparin injections na maaaring itigil nang mas malapit sa operasyon.

Ang mga bagong tablet: DOACs (apixaban/Eliquis, rivaroxaban/Xarelto, dabigatran/Pradaxa, edoxaban). Bawat isa ay humahadlang sa isang tiyak na factor ng pagkakadugo, at mabilis itong nililinis ng katawan, na may half-life na humigit-kumulang 12 oras. Dahil mabilis itong lumalabas, karaniwang kailangan lang itong itigil 1–2 araw bago ang operasyon. Mas mahaba ang paghihintay kung hindi mabuti ang paglilinis ng iyong bato ng gamot (lalo na ang dabigatran, na karamihan ay lumalabas sa pamamagitan ng bato) o kung mataas ang risk ng pagdurugo sa operasyon. Hindi nito kailangan ang INR monitoring at karaniwang walang bridging.

Heparin / low-molecular-weight heparin (enoxaparin/Clexane) injections. Short-acting; ginagamit para bridging sa warfarin o para pigilan ang pagkakadugo. Dahil ito ay nawawala sa loob ng ilang oras, ang huling dose ay simpleng tinatama ang oras nito malapit sa operasyon (karaniwan ay humigit-kumulang 24 oras bago ang isang treatment dose).

Bakit ganito ang timing — sa isang linya

Nakadepende ito sa paraan ng paggana ng gamot at sa paraan ng paglilinis ng iyong katawan dito: ang mga irreversible na platelet drugs ay nangangailangan ng pagbuo ng mga bagong platelet (humigit-kumulang isang linggo); ang warfarin ay nangangailangan ng paglilinis ng mga lumang clotting factors (humigit-kumulang 5 araw); ang mga DOACs ay simpleng lumalabas lamang (isang araw o dalawa). Ang bawat plano ay sinusukat din ang iyong personal na clot risk, kaya’t maaaring magkaiba ang mga instruksyon para sa dalawang tao na gumagamit ng parehong gamot.

Ang mga dapat mong gawin

  • Dalhin ang eksaktong listahan ng lahat ng gamot na iyong ininom sa iyong pre-operative assessment, kasama ang aspirin at mga supplement tulad ng fish oil, na nakakaapekto rin sa pagdurugo.
  • Sundin ang tiyak na nakasulat na petsa ng pagtigil at pagpapatuloy na ibinigay sa iyo. Ito ay idinisenyo para sa iyong gamot, sa iyong function ng bato, at sa iyong operasyon.
  • Huwag kailanman tigilin, simulan, o baguhin ang blood thinner nang sarili, at huwag magpalagay na ang iyong timing ay katulad ng kaibigan mo.
  • Ipahayag sa bawat clinician na kasangkot na gumagamit ka nito.

Pagkatapos ng iyong operasyon

Ang mga blood thinner ay muling sisimulan kapag naayos na ang panganib ng pagdurugo, minsan ay loob ng isang araw, minsan ay mas matagal pagkatapos ng operasyon na may mataas na panganib ng pagdurugo. Ipapaliwanag sa iyo kung kailan ito eksaktong sisimulan. Ang dugo na pigilan ng gamot ay hindi nawawala dahil sa operasyon, kaya’t ang pag-simula sa tamang oras ay kasing-importante ng paghinto.

Tumawag sa amin kung

  • Napagtanto mong kumain ka ng isang dosis na sinabing iwasan, o naiwan ang isang dosis na sinabing kumain
  • Mayroon kang hindi karaniwang malalim na pamumula o pagdurugo, dugo sa ihi o dumi, itim at malagkit na dumi, o pagdurugo na hindi humihinto
  • Hindi ka sigurado kung ano ang gagawin sa iyong blood thinner bago ang operasyon: laging magtanong kaysa maghula

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