Thromb Haemost 2013; 110(03): 515-522
DOI: 10.1160/TH12-11-0868
Review Article
Schattauer GmbH

The perioperative management of new direct oral anticoagulants: a question without answers

Raquel Ferrandis
1   Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital Clínic Universitari, Valencia; University of Valencia, Spain
,
Jordi Castillo
2   Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital del Mar, Barcelona, Spain
,
José de Andrés
3   Department of Anaesthesiology, Critical Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, University of Valencia, Spain
,
Carmen Gomar
4   Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital Clínic de Barcelona, Universitat de Barcelona, Spain
,
Aurelio Gómez-Luque
5   Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital Universitario Virgen de la Victoria, University of Málaga, Spain
,
Francisco Hidalgo
6   Department of Anaesthesiology, Critical Care and Pain Therapy, Clínica University of Navarra, Spain
,
Juan V. Llau
1   Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital Clínic Universitari, Valencia; University of Valencia, Spain
,
Pilar Sierra
7   Department of Anaesthesiology, Critical Care and Pain Therapy, Fundación Puigvert (IUNA), Barcelona, Spain
,
Luis M. Torres
8   Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital Universitario Puerta del Mar, Cádiz, Spain
› Author Affiliations
Further Information

Publication History

Received: 26 November 2012

Accepted after major revision: 25 May 2013

Publication Date:
22 November 2017 (online)

Summary

New direct oral anticoagulant agents (DOAC) are currently licensed for thromboprophylaxis after hip and knee arthroplasty and for longterm prevention of thromboembolic events in non-valvular atrial fibrillation as well as treatment and secondary prophylaxis of venous thromboembolism. Some other medical indications are emerging. Thus, anaesthesiologists are increasingly likely to encounter patients on these drugs who need elective or emergency surgery. Due to the lack of experience and data, the management of DOAC in the perioperative period is controversial. In this article, we review available information and recommendations regarding the periprocedural management of the currently most clinically developed DOAC, apixaban, dabigatran, and rivaroxaban. We discuss two trends of managing patients on DOAC for elective surgery. The first is stopping the DOAC 1–5 days before surgery (depending on the drug, patient and bleeding risk) without bridging. The second is stopping the DOAC 5 days preoperatively and bridging with low-molecular-weight heparin. The management of patients on DOAC needing emergency surgery is also reviewed. As no data exist for the use of haemostatic products for the reversal of the anticoagulant effect in these cases, rescue treatment recommendations are proposed.