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

Raquel Ferrandis; Jordi Castillo; José de Andrés; Carmen Gomar; Aurelio Gómez-Luque; Francisco Hidalgo; Juan V. Llau; Pilar Sierra; Luis M. Torres

doi:10.1160/TH12-11-0868

Thrombosis and Haemostasis, Table of Contents

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

¹Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital Clínic Universitari, Valencia; University of Valencia, Spain

,

Jordi Castillo

²Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital del Mar, Barcelona, Spain

,

José de Andrés

³Department of Anaesthesiology, Critical Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, University of Valencia, Spain

,

Carmen Gomar

⁴Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital Clínic de Barcelona, Universitat de Barcelona, Spain

,

Aurelio Gómez-Luque

⁵Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital Universitario Virgen de la Victoria, University of Málaga, Spain

,

Francisco Hidalgo

⁶Department of Anaesthesiology, Critical Care and Pain Therapy, Clínica University of Navarra, Spain

,

Juan V. Llau

¹Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital Clínic Universitari, Valencia; University of Valencia, Spain

,

Pilar Sierra

⁷Department of Anaesthesiology, Critical Care and Pain Therapy, Fundación Puigvert (IUNA), Barcelona, Spain

,

Luis M. Torres

⁸Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital Universitario Puerta del Mar, Cádiz, Spain

› Author Affiliations

Abstract

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.

Keywords

Anticoagulants - thrombosis - haemorrhage - perioperative - dabigatran - apixaban - rivaroxaban

Full Text

References

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