Activated prothrombin complex concentrate to reverse the factor Xa inhibitor (apixaban) effect before emergency surgery: a case series

Anticoagulant-related bleeding carries considerable morbidity and mortality. Major or life-threatening bleeding is among the most severe of these complications. As the number of patients treated with direct oral anticoagulants (DOACs) continues to increase, so does the number of DOAC-related bleeding events. The incidence of CRNM bleeding related to DOAC therapy ranges from 15 to 18% per 100-year patients, while the incidence of major bleeding ranges from 2.71 to 3.6%. Many of these bleeding events can be prevented with tailored dosing regimens or proper peri-procedural management. When unable to be prevented, DOAC-related bleeding can lead to significant long-term disability or death. Management with newer reversal agents such as andexanet alfa and idarucizumab, as well as prothrombin complex concentrates, may improve outcomes for patients with DOAC-related bleeding. The purpose of this review is to explore strategies for preventing and treating bleeding in patients receiving DOACs for anticoagulant therapy. Key PointsDOAC-related bleeding is a serious, often life-threatening, complication. Some bleeding events can be prevented with tailored dosing regimens and proper periprocedural management. However, when major/life-threatening bleeding occurs, management with specific reversal agents or PCCs may reduce overall mortality.Reviewing these concepts may help to better prepare healthcare professionals to provide safe and effective care to their patients.

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“…Three patients received aPCC at doses of 25 units/kg and had beneficial outcomes. No thrombotic complications were observed [72].…”

Section: Activated Prothrombin Complex Concentratementioning

confidence: 85%

Prevention and Treatment of Bleeding with Direct Oral Anticoagulants

Crawley

Anderson

2020

Drugs

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“…Post-cardiopulmonary bypass options to treat coagulopathy include use of the following: antifibrinolytic agents; standard blood products such as platelets, fresh frozen plasma, and cryoprecipitate; recombinant factors such as prothrombin complex concentrate, activated factor VIIa, and human fibrinogen concentrate; and thoughtful administration of anti-factor Xa antidotes. 54,55…”

Section: Novel or Non-vitamin K Oral Anticoagulantsmentioning

confidence: 99%

When to Consider Deferral of Surgery in Acute Type A Aortic Dissection: A Review

Sabe

Percy

Kaneko

et al. 2021

The Annals of Thoracic Surgery

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Background Acute type A aortic dissection (ATAAD) is a surgical emergency with an operative mortality of up to 30%, a rate which has not changed meaningfully in over two decades. A growing body of research has highlighted several comorbidities and presenting factors in which delay or permanent deferral of surgery may be considered; however, modern comprehensive summative reviews are lacking. The urgency and timing of this review are underscored by significant challenges in resource utilization posed by the COVID-19 pandemic. This review provides an update on the current understanding of risk assessment, surgical candidacy, and operative timing in patients with ATAAD. Methods A literature search was conducted through PubMed and Embase databases to identify relevant studies relating to risk assessment in ATAAD. Articles were selected via group consensus based on quality and relevance. Results Several patient factors have been identified which increase risk in ATAAD repair. In particular, frailty, advanced age, prior cardiac surgery, and use of novel anticoagulant medications have been studied. The understanding of malperfusion syndromes has also expanded significantly, including recommendations for surgical delay. Finally, approaches to triage have been significantly influenced by resource limitations related to the ongoing COVID-19 pandemic. While medical management remains a reasonable option in carefully selected patients at prohibitive risk for open surgery, endovascular therapies for treatment of ATAAD are rapidly evolving. Conclusions Early surgical repair remains the preferred treatment for most patients with ATAAD, however, improvements in risk stratification should guide appropriate delay or permanent deferral of surgery in select individuals.

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“…A total of 8% of patients had thrombotic events within 30 days of their bleed reversal. The utilization of PCCs at the time of transplant surgery is limited to case reports 67 …”

Section: Periprocedural Management and Reversal Of Doac Therapymentioning

confidence: 99%

Use of direct‐acting oral anticoagulants in solid organ transplantation: A systematic review

et al. 2020

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The use of direct‐acting oral anticoagulants (DOACs) has increased secondary to the mounting evidence for comparable efficacy and potentially superior safety to vitamin K antagonists (VKAs) in the general population. However, insufficient data regarding DOAC use in solid organ transplant (SOT) recipients and numerous pharmacokinetic and pharmacodynamic considerations limit their use in this highly selected patient population. A systematic review of recent clinical evidence on the safety and efficacy of DOACs compared to VKAs in SOT recipients was conducted. Additional considerations including transplant‐specific strategies for DOAC reversal and common pharmacokinetic/pharmacodynamic concerns were also reviewed. Although current evidence is limited to single‐center retrospective analyses, DOACs, especially apixaban, appear to be a safe and effective alternative to VKAs for SOT recipients with stable graft function and without drug‐drug interactions. Reliable data on DOAC reversal at the time of transplant surgery are lacking, and clinicians should consider idarucizumab, andexanet alfa, and other non‐specific reversal agents on an individual patient basis. There is no evidence supporting deviations from the Food and Drug Administration labeling recommendations for DOAC dosing in the setting of drug‐drug interactions, obesity, and renal function, especially in patients on hemodialysis.

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Activated prothrombin complex concentrate to reverse the factor Xa inhibitor (apixaban) effect before emergency surgery: a case series

Cited by 16 publications

References 16 publications

Prevention and Treatment of Bleeding with Direct Oral Anticoagulants

Prevention and Treatment of Bleeding with Direct Oral Anticoagulants

When to Consider Deferral of Surgery in Acute Type A Aortic Dissection: A Review

Use of direct‐acting oral anticoagulants in solid organ transplantation: A systematic review

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