第一先評估手術出血風險
手術出血風險評估表 (先確定術式的出血風險等級)
高出血風險手術 High bleeding risk procedures:
(2 day risk of major bleed 2-4%)
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低出血風險手術Low bleeding risk procedures
(2 day risk of major bleed 0-2%)
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any major operation of duration >45min
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重大手術 >45分鐘,
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tooth extractions
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拔牙 |
polypectomy
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息肉切除
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GI endoscopy ± biopsy
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腸胃道內視鏡 ± 組織切片
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spinal or epidural anesthesia, lumbar diagnostic puncture
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脊椎或硬膜外麻醉，腰椎診斷穿刺
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endosonography without fine-needle aspiration
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內視鏡超音波 (未做細針穿刺),
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kidney biopsy
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腎臟組織切片
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axillary node dissection
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腋下淋巴切除
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liver biopsy
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肝臟組織切片
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central venous catheter removal
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中央靜脈導管拔除
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neurosurgical/urologic/head and neck/abdominal/breast cancer surgery
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神經外科/泌尿科/頭頸部/腹部/乳房癌症手術
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cutaneous and bladder/ prostate/ thyroid/ breast/ lymph node biopsies
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皮膚及膀胱/攝護腺/甲狀腺/乳房/淋巴結組織切片
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endoscopically guide fine-needle aspiration
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內視鏡導引細針穿刺
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bronchoscopy ± biopsy
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支氣管鏡檢查 ± 組織切片
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transurethral prostate resection
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經尿道前列腺切除術
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noncoronary angiography
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非冠狀動脈造影
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foot/hand/shoulder surgery
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足部/手部/肩部手術
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cholecystectomy
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膽囊切除術
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vascular and general surgery
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血管及一般手術
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hemorrhoidal surgery
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痔瘡手術
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biliary sphincterectomy
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膽道括約肌切開術
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abdominal hernia repair
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腹腔疝氣修補
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variceal treatment
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靜脈曲張治療
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cataract and noncataract eye surgery
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白內障或非白內障手術
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laminectomy
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椎板切除術
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arthroscopic surgery lasting<45min
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關節鏡手術 < 45分鐘
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abdominal aortic aneurysm repair
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腹主動脈瘤修補
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carpal tunnel repair
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腕道症候群修復
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pneumatic dilation
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食道氣囊擴張術
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abdominal hysterectomy
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腹式子宮切除術 |
hip replacement
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髖關節置換
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dilatation and curettage
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子宮擴刮術
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knee replacement
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膝關節置換
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hydrocele repair
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陰囊積水修復
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heart valve replacement
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心臟瓣膜置換
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biliary/pancreatic stent without sphincterectomy
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膽/胰管支架 (不含括約肌切開術)
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coronary artery bypass
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冠狀動脈繞道手術
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pacemaker and cardiac defibrillator insertion and electrophysiologic testing
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心律調節器、心臟除顫器安裝及電生理學測試
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第二評估病人的血栓風險
2血栓風險評估 (風險分為高、中、低)
手術期間血栓風險 (ACCP, UpToDate)
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抗凝血劑適應症
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機械性心臟瓣膜
Mechanical Heart Valve
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心房顫動
Atrial Fibrillation
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靜脈栓塞
VTE
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• Mitral valve prosthesis
• Cage-ball or tilting disc aortic valve prosthesis
• CVA/TIA < 6 mons prior
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• CHA2DS2-VASc score ≥ 6 (or CHADS2 score 5-6)
• CVA/TIA < 3 mons prior
• Rheumatic valvular heart disease
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• VTE < 3 mons prior
• Severe thrombophilia(易血栓形成體質)†
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• Bileaflet aortic valve and other risk factors‡
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• CHA2DS2-VASc score 4-5 (or CHADS2 score 3- 4)
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• VTE 3–12 mons prior
• Nonsevere thrombophilia§
• Recurrent VTE
• Active cancer (treated within 6 mons or palliative)
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• Bileaflet aortic valve without other risk factors for stroke
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• CHA2DS2-VASc score 2-3 (or CHADS2 score 0-2 without prior CVA/TIA)
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• VTE >12 mons prior without other risk factors
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• VTE >12 mons prior without other risk factors
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†缺乏 protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities.
‡CVA 危險因子: atrial fibrillation, prior CVA/TIA, hypertension, diabetes, congestive heart failure, age >75 years.
§Heterozygous factor V Leiden or prothrombin gene mutation.
CVA =cerebrovascular accident; TIA =transient ischemic attack; VTE =venous thromboembolism
CHADS2 and CHA2DS2-VASc Risk (計算總點數 )
CHADS2
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Adjusted stroke rate (%/year)
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1 point
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糖尿病心臟衰竭
高血壓
年齡 ≥75
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Total Points (總點數)
0: 1.9%
1: 2.8%
2: 4.0%
3: 5.9%
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4: 8.5%
5: 12.5%
6: 18.2%
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2 points
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中風 (Stroke), 短暫性腦缺血 (TIA), 或 全身栓塞(systemic embolism)
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CHA2DS2-VASc
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Annual stroke rate (%/year)
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1 point
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心臟衰竭
高血壓
糖尿病
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Total Points
0: 0%
1: 1.3%
2: 2.2%
3: 3.2%
4: 4.0%
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5: 6.7%
6: 9.8%
7: 9.6%
8: 12.5%
9: 15.2%
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2 points
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年齡 ≥75
中風, 短暫性腦缺血(TIA), 或 全身性栓塞(systemic embolism)
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1 point
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血管疾病 (MI, PAD, aortic atheroma)
年齡 65 to 74 歲
性別 女性
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Anticoagulants- 手術期間之處置 (病人的用藥)
Anticoagulants
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腎功能及劑量
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手術前停藥時間
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恢復服藥
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註
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高出血風險手術1
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低出血風險手術1
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高出血風險手術1
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低出血風險手術1
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Warfarin (Coumadin)
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見流程圖一
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見流程圖一
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見流程圖一
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見流程圖一
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Dabigatran (Pradaxa)
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CrCl > 50 mL/min
劑量 150 mg bid
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術前 2 天停藥
(最後一次劑量-術前 3 天)
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術前 1 天停藥
(最後一次劑量-術前 2 天)
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術後 48-72 h (高血栓風險病人2 可考慮此期間給予 low dose LMWH3)
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術後 24 h
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若病人具極高血栓風險且術後無法口服藥品（如腸道手術），應考慮術後 LMWH bridging3
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CrCl: 30-50 mL/min
劑量 150 mg bid
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術前 4 天停藥
(最後一次劑量-術前 5 天)
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術前 2 天停藥
(最後一次劑量-術前 3 天)
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Rivaroxaban (Xarelto)
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CrCl > 50 mL/min
劑量 20 mg qd
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術前 2 天停藥
(最後一次劑量-術前 3 天)
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術前 1 天停藥
(最後一次劑量-術前 2 天)
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CrCl: 15-50 mL/min
劑量 15 mg qd
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Apixaban (Eliquis)
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CrCl >50 mL/min
劑量 5 mg bid
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CrCl 50-15 mL/min
劑量 2.5 mg bid
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Edoxaban (Lixiana)
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CrCl: 50-95 mL/min
劑量 60 mg qd
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CrCl 50-15 mL/min
劑量 30 mg qd
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LMWH
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術前 24 h (therapeutic dose)
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24 h
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術後第 2-3天
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術後 24 h
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Heparin (iv)
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術前 6 h
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6 h
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術後第 2-3天
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術後 24 h
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Antiplatelets- 手術期間之處置
Antiplatelets
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停藥時間 (高出血風險1)
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停藥時間 (低出血風險1)
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恢復服藥
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註
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Aspirin
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見流程圖二
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見流程圖二
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見流程圖二
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P2Y12 Inhibitor
Clopidogrel (Plavix) Ticagrelor (Brilinta)
Prasugrel (Effient) Ticlopidine (Licodine, Panaldine)
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見流程圖二
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見流程圖二
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見流程圖二
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NSAIDS-COX1 inhibitors
Ibuprofen, diclofenac, ketoprofen, ketorolac
Naproxen
indomethacin
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（藥品 4-5 個半衰期）
1 天
3-4 天
2 天
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不需停藥
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術後若已達止血狀態可回復服用 (24h)
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若病人疼痛控制需要，可以COX2 inhibitor 取代
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NSAIDS-COX2 inhibitors
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3 天 (UpToDate 建議)
不停藥 (ASRA guideline 建議)
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不需停藥
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術後若已達止血狀態可回復服用(24h)
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Selective COX2 inhibitors 不影響血小板功能，不需停藥
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Dipyridamole (Persantin, Sandel)
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2 天
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不需停藥
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24h
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Cilostazol (Pletaal, Citazol)
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2-3 天
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不需停藥
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24h
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References:
1. UpToDate-Perioperative management of patients receiving anticoagulantsnts
2. UpToDate- Perioperative medication management
3. Perioperative management of antithrombotic therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed: ACCP guideline. (CHEST 2012; 141(2)(Suppl): e326S–e350S)
4. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients with Coronary Artery Disease
5. 2018 EHRA Practical Guide on NOACs in AF (European Heart Journal (2018) 39, 1330–1393)
6. American Society of Regional Anesthesia and Pain Medication (ASRA): Evidence-based guideline on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy, 4th ed.(2018) (Reg Anesth Pain Med 2018;43: 263–309)
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