Perioperative Management of Patients Receiving New Anticoagulants

Abstract

There is an increased use of oral anticoagulants for the prevention of venous and arterial thrombosis. Vitamin-K antagonists have been used for decades as the main oral anticoagulants but they have the draback a complex therapeutic management, slow onset of action and by a different oral intake caused by dietary vitamin K intake. New non-vitamin K antagonist oral anticoagulants (NOACs) have been developed to overcome the limitations of warfarin. Their management is easier as it requires a fixed daily dose without coagulation monitoring. Although their therapeutic profile is safe, proper attention should be paid in case of unexpected need for the reversal of their coagulation effect and in case a patient needs to have a scheduled surgery. For non-acute cardiac surgery, discontinuation of NOACs should start at least 48 hours prior surgery. Intracranial bleedings associated with NOACs are less dangerous comparing to those warfarin-induced. NOACs need to be stopped ≥24 hours in case of elective surgery for low bleeding-risk procedures and ≥48 hours for high bleeding-risk surgery in patients with normal renal function and 72 hours in case of reduced CrCl < 80. The therapy with NOACs should be resumed from 48 to 72 hours after the procedure depending on the perceived bleeding, type of surgery and thrombotic risks. There are some available NOAC reversal agents acting within 5 to 20 minutes. In case of lack of reversal agent, adequate diuresis, renal replacement therapy and activated charcoal in case of recent ingestion should be considered.

Addressing Transplant Candidacy When Evaluating Safety of Direct Oral Anticoagulant Agents in Patients on Hemodialysis

“…The optimal time of DOAC discontinuation before surgery has not been established, particularly in patients with kidney failure. 2 Reversal agents for DOACs remain expensive and rare and, as with DOACs, the safety and efficacy of these agents in the kidney failure population is lacking. Although table 2 of the De Vriese et al manuscript notes one trial participant who discontinued rivaroxaban prematurely due to "registration on the transplant list," the authors do not report how many other subjects were already on a transplant waiting list.…”

“…Alternatively, prothrombin complex concentrates can be used, despite not being specific reversal therapy agents, but published experience at the time of emergency surgery is limited to case reports. 2 A survey of reversal practices among adult transplant programs in the United States indeed revealed that, although 64% of kidney transplant programs allow patients to remain on direct oral anticoagulants (DOAC) while on the transplant waiting list, only 7.8% reported routine use of DOAC reversal agents. 3 This large practice variability calls for more guidance by professional societies, pending reliable research in this context.…”

“…Although the timely discontinuation of DOACs is easily arranged before living-donor kidney transplantation, transplants from deceased donors, which account for two thirds of transplants in the United States, are nonelective procedures that do not accommodate advanced planning. The optimal time of DOAC discontinuation before surgery has not been established, particularly in patients with kidney failure 2 . Reversal agents for DOACs remain expensive and rare and, as with DOACs, the safety and efficacy of these agents in the kidney failure population is lacking.…”

Effects of heparinoid bridging in patients with mechanical heart valves

“…Heparinoid bridging for anticoagulation "Bridging" is the act of administering short-acting and reversible anticoagulants while OAT is interrupted, and the international normalized ratio (INR) is subtherapeutic. This provides the patient with TE protection until the patient is safely transitioned back on to OAT within the therapeutic range (Douketis & Lip, 2019).…”