‘New’ direct oral anticoagulants in the perioperative setting

Abstract

NOACs like dabigatran etexilate, rivaroxaban, apixaban and edoxaban are effective alternatives to warfarin in primary and secondary prophylaxis of thromboembolic conditions. In the perioperative setting, some uncertainties and evidence gaps remain in estimating the bleeding risks associated with surgical procedures, emergency trauma and neuroaxial anesthesia. A discontinuation of NOACs should be at least 1 day before elective operation. Renal and liver impairment, older age, or co-medications could afford longer intervals. As no specific reversal agents are yet available for life-threatening bleeding or emergency surgery; nonspecific prohemostatic therapies are mainly recommended. Oral charcoal, application of tranexamic acid or hemodialysis could bring additional benefit depending on the individual NOAC. Practitioners need to be aware that NOACs can interfere in different pathways with the measurement of common hemostasis parameters. Estimating the bleeding risks and reversal strategies requires careful evaluation also in the light of a potential risk of thromboembolic complications. In difference to warfarin, 'bridging' concepts are not generally recommended for NOACs.

Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy

“…In this survey, almost 90 % of all respondents considered the preinjury intake of anticoagulants including NOACs as an increasing risk to bleeding trauma patients and half of all respondents declared these drugs to potentially cause ''major'' problems when treating these patients as no specific reversal agents are yet available [36]. However, there seem to be geographical differences for the existence of this threat as these novel agents are prescribed predominately in the developed countries, but this needs to be further evaluated based upon the data obtained from this survey.…”

Management of anticoagulant and antiplatelet therapy in patients undergoing interventional pulmonary procedures

“…In addition, we recommend discontinuing warfarin 5 days prior to the procedure and monitoring the INR to ensure that it has normalised. In the event that urgent reversal is needed, we recommend normalising the coagulopathy with use of reversal agents [31][32][33][34][35] if clinically possible before the procedure. However, clinical discretion, urgency of the procedure and benefit versus risk should be taken into account before the decision is made to proceed with or forgo these procedures.…”

Using New Oral Anticoagulants in Patients Undergoing Major Orthopedic Surgery

“…The use of NOAC, like the use of LMWH, can be associated with epidural hematoma [46,57,58]. None of the NOAC should be given until at least 6 h after epidural catheter removal.…”

“…None of the NOAC should be given until at least 6 h after epidural catheter removal. If traumatic lumbar puncture occurred (when placing the epidural catheter), then dosing should be delayed for 24 h [57,58].…”