Direct oral anticoagulants: peri‐operative considerations and controversies

Charlesworth, Michael; Arya, Roopen

doi:10.1111/anae.14455

Cited by 7 publications

(4 citation statements)

References 28 publications

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“…16 Increasing evidence reports the use of four-factor PCC to reverse the effects of apixaban and rivaroxaban; however, the quality of evidence is low and there have been concerns around thromboembolic complications. 16,17 Ciraparantag, an investigational drug for reversing the effects of all DOACs and low molecular weight heparin, is still in early development. 18…”

Section: Preoperative Medicationsmentioning

confidence: 99%

Hemostatic Management of Extracorporeal Circuits Including Cardiopulmonary Bypass and Extracorporeal Membrane Oxygenation

Fang

Navaei

Hensch

et al. 2019

Semin Thromb Hemost

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Cardiopulmonary bypass and extracorporeal membrane oxygenation (ECMO) cause hemostatic derangements that can predispose patients to both bleeding and thrombotic complications. Often, patients present for urgent surgery while taking medications including antiplatelet agents, vitamin K antagonists, and direct oral anticoagulants, which must be recognized, monitored, and managed. During extracorporeal circulation, appropriate anticoagulation, most commonly with heparin, is required to maintain blood flow and avoid thrombotic complications. However, anticoagulation and other effects of extracorporeal circuits can also have an undesired consequence of bleeding. Extracorporeal circulation leads to coagulopathy that may require therapy with blood products such as platelets, cryoprecipitate, and plasma in case a patient bleeds. Platelet dysfunction related to exposure to a foreign circuit is a primary concern, as is the development of acquired von Willebrand syndrome, which frequently remains undetected on routine testing. Hemorrhagic complications in ECMO, such as intracranial hemorrhage, pulmonary hemorrhage, and hemithorax, can occur. Hemostatic agents including antifibrinolytics, desmopressin, fibrinogen concentrates, and other factor concentrates may be needed to achieve hemostasis in these often-challenging patients. Managing bleeding on extracorporeal support requires careful monitoring and a thoughtful approach.

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Section: Preoperative Medicationsmentioning

confidence: 99%

Hemostatic Management of Extracorporeal Circuits Including Cardiopulmonary Bypass and Extracorporeal Membrane Oxygenation

Fang

Navaei

Hensch

et al. 2019

Semin Thromb Hemost

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“…This may be due to the newer nature of the DOACs. Clinicians’ knowledge and guidelines have previously been described as variable (Charlesworth & Arya 2018). Clear guidelines and standardised care between centres are required, as the prevalence of DOACs increases further.…”

Section: Discussionmentioning

confidence: 99%

The importance of perioperative optimisation to facilitate safe regional anaesthesia and their improved outcomes in fracture neck of femur patients

Gowers

Greenhalgh

Dyson

et al. 2021

Journal of Perioperative Practice

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Background: Hip fractures are common presentations to orthopaedic departments, and their surgical management often results in blood transfusions. Compared with general anaesthesia, regional anaesthesia reduces the need for transfusions and mortality in the wider surgical population. Aims: In hip fracture patients, our primary outcome measure was to examine any relationship between anaesthetic modality and transfusion rates. The secondary outcome measure was to assess the relationship between anaesthetic modality and one-year mortality. Methods: A retrospective cohort study of 280 patients was carried out in 2017 and 2018. Data were collected from patient records, local transfusion laboratory and the national hip fracture database. Results: A total of 59.6% had regional and 40.4% general anaesthesia. Regional anaesthesia patients were younger with fewer comorbidities (p < .05). About 19.8% regional and 34.5% general anaesthesia patients received transfusions (odds ratio (OR) = 0.47, p < .05); 13.6% were taking anticoagulants and were less likely to receive a regional anaesthetic (31.6% versus 64%, OR = 0.26, p < .05). One-year mortality was 27% for regional and 37% for general anaesthetic patients (OR = 0.64, p = .09). Conclusion: Regional anaesthesia halved the risk of blood transfusion. Anticoagulated patients were 74% less likely to receive regional anaesthetics, but had no additional transfusion risk. With optimisation, a larger proportion of patients could have regional anaesthesia.

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“…The introduction of Direct or Novel Oral Anti-Coagulants (DOAC) marked a revolution in medi-cal management by providing an alternative to Vitamin K antagonists which are limited by their narrow therapeutic window, variable dose-response, plethora of drug interactions and dose monitoring requirements (1). These benefits are offset in the acute emergency setting where decision making is complicated by difficulties in measuring drug concentrations and in reversing the anticoagulant (2,3). Hip fractures remain a common trauma presentation in older populations and an increasing number of these patients are presenting while anticoagulated by DOAC (4)(5)(6)(7)(8)(9)(10).…”

Section: Introductionmentioning

confidence: 99%

The impact of direct oral anti-coagulants on hip fracture management : a systematic review and meta-analysis

Holmes¹,

Bahnam²

2021

Acta Orthop Belg

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Hip fractures are a common presentation in the elderly, a group who commonly have co-morbidities requiring the use of anticoagulants. Recently, direct oral anti-coagulants (DOAC) have become a popular method of anticoagulating patients. The primary aim of this review is to determine if the use of DOAC in elderly patients with hip fractures results in delays to theatre and/or an increased mortality risk. Major databases including Pubmed, MEDLINE and Embase were searched for relevant studies and the included studies reference lists were screened for further studies. A total of 6 studies were included in meta-analysis which was undertaken using RevMan software with 95% confidence interval (CI). Compared to control groups, patients who were anticoagulated with DOAC and required operative management of a hip fracture experienced a statistically significant delay to treatment. However independent analysis showed these patients did not experience an increased mortality risk when compared to the control group. While data is limited, treating clinicians should be comforted by these findings as operative manage- ment can be safely delayed to reduce the risk of intraoperative bleeding.

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Direct oral anticoagulants: peri‐operative considerations and controversies

Abstract: Direct oral anticoagulants (DOAC) have a number of advantages over warfarin, such as: fixed dosing; no requirement for routine monitoring; predictable pharmacokinetics; fewer interactions; and a rapid onset/offset of clinical effect. Despite

Cited by 7 publications

References 28 publications

Hemostatic Management of Extracorporeal Circuits Including Cardiopulmonary Bypass and Extracorporeal Membrane Oxygenation

Hemostatic Management of Extracorporeal Circuits Including Cardiopulmonary Bypass and Extracorporeal Membrane Oxygenation

The importance of perioperative optimisation to facilitate safe regional anaesthesia and their improved outcomes in fracture neck of femur patients

The impact of direct oral anti-coagulants on hip fracture management : a systematic review and meta-analysis

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