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Updates in the perioperative and emergency management of non-vitamin K antagonist oral anticoagulants.

Faraoni D, Levy JH, Albaladejo P, Samama CM, Groupe d’Intérêt en Hémostase Périopératoi - Crit Care (2015)

Bottom Line: Due to the lack of good clinical studies involving adequate monitoring and reversal therapies, management requires knowledge and understanding of pharmacokinetics, renal function, drug interactions, and evaluation of the surgical bleeding risk.As a consequence, a multimodal approach should be taken which includes the administration of 25 to 50 U/kg 4-factor prothrombin complex concentrates or 30 to 50 U/kg activated prothrombin complex concentrate (FEIBA®) in some life-threatening situations.Finally, further studies are needed to clarify the ideal therapeutic intervention.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA. david.faraoni@childrens.harvard.edu.

ABSTRACT
Perioperative management of patients treated with the non-vitamin K antagonist oral anticoagulants is an ongoing challenge. Due to the lack of good clinical studies involving adequate monitoring and reversal therapies, management requires knowledge and understanding of pharmacokinetics, renal function, drug interactions, and evaluation of the surgical bleeding risk. Consideration of the benefit of reversal of anticoagulation is important and, for some low risk bleeding procedures, it may be in the patient's interest to continue anticoagulation. In case of major intra-operative bleeding in patients likely to have therapeutic or supra-therapeutic levels of anticoagulation, specific reversal agents/antidotes would be of value but are currently lacking. As a consequence, a multimodal approach should be taken which includes the administration of 25 to 50 U/kg 4-factor prothrombin complex concentrates or 30 to 50 U/kg activated prothrombin complex concentrate (FEIBA®) in some life-threatening situations. Finally, further studies are needed to clarify the ideal therapeutic intervention.

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Related in: MedlinePlus

Proposed algorithm for peri-operative management of non-vitamin K antagonist oral anticoagulants. CrCl, creatinine clearance; LMWH, low molecular weight heparin; NA, not applicable; NOAC, non-vitamin K antagonist oral anticoagulant; PCC, prothrombin complex concentrate; TE, thromboembolism.
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Fig1: Proposed algorithm for peri-operative management of non-vitamin K antagonist oral anticoagulants. CrCl, creatinine clearance; LMWH, low molecular weight heparin; NA, not applicable; NOAC, non-vitamin K antagonist oral anticoagulant; PCC, prothrombin complex concentrate; TE, thromboembolism.

Mentions: Different groups have published recommendations for perioperative management [15-19]. As recently recommended by the European Society of Cardiology [9], surgical procedures should be classified in three different categories: (i) interventions not requiring discontinuation of anticoagulation (for example, dental, ophthalmology, and superficial surgeries); (ii) intervention with low bleeding risk (for example, prostate or bladder biopsy, angiography, pacemaker implementation); or (iii) intervention with high bleeding risk (spinal or epidural anesthesia, lumbar diagnostic puncture, cardiothoracic surgery, abdominal surgery, major orthopedic surgery, liver biopsy, transurethral prostate resection, and kidney biopsy). Based on these guidelines [9,16,18], the three NOACs currently available should be stopped 24 hours before surgery with a low bleeding risk, and at least 48 hours and up to 96 hours before surgery with a high bleeding risk. In case of severe renal impairment (CrCl <30 ml/minute), interruption of direct factor Xa inhibitors should be delayed to 48 hours. For dabigatran, delays should be progressively prolonged based on CrCl (Figure 1) and potential laboratory testing should be considered to determine residual effects of the agents. It is important to mention that the use of dabigatran in patients with severe renal impairment (CrCl <30 ml/minute) is not recommended. Another way to manage these agents is to define a more conservative approach and to recommend the same interruption period for all the NOACs. With this approach, interruption should be 4 days in all patients and, in some cases (elderly, severe renal insufficiency), the interruption should approach 5 days. Additional studies are needed to optimize perioperative management.Figure 1


Updates in the perioperative and emergency management of non-vitamin K antagonist oral anticoagulants.

Faraoni D, Levy JH, Albaladejo P, Samama CM, Groupe d’Intérêt en Hémostase Périopératoi - Crit Care (2015)

Proposed algorithm for peri-operative management of non-vitamin K antagonist oral anticoagulants. CrCl, creatinine clearance; LMWH, low molecular weight heparin; NA, not applicable; NOAC, non-vitamin K antagonist oral anticoagulant; PCC, prothrombin complex concentrate; TE, thromboembolism.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4414429&req=5

Fig1: Proposed algorithm for peri-operative management of non-vitamin K antagonist oral anticoagulants. CrCl, creatinine clearance; LMWH, low molecular weight heparin; NA, not applicable; NOAC, non-vitamin K antagonist oral anticoagulant; PCC, prothrombin complex concentrate; TE, thromboembolism.
Mentions: Different groups have published recommendations for perioperative management [15-19]. As recently recommended by the European Society of Cardiology [9], surgical procedures should be classified in three different categories: (i) interventions not requiring discontinuation of anticoagulation (for example, dental, ophthalmology, and superficial surgeries); (ii) intervention with low bleeding risk (for example, prostate or bladder biopsy, angiography, pacemaker implementation); or (iii) intervention with high bleeding risk (spinal or epidural anesthesia, lumbar diagnostic puncture, cardiothoracic surgery, abdominal surgery, major orthopedic surgery, liver biopsy, transurethral prostate resection, and kidney biopsy). Based on these guidelines [9,16,18], the three NOACs currently available should be stopped 24 hours before surgery with a low bleeding risk, and at least 48 hours and up to 96 hours before surgery with a high bleeding risk. In case of severe renal impairment (CrCl <30 ml/minute), interruption of direct factor Xa inhibitors should be delayed to 48 hours. For dabigatran, delays should be progressively prolonged based on CrCl (Figure 1) and potential laboratory testing should be considered to determine residual effects of the agents. It is important to mention that the use of dabigatran in patients with severe renal impairment (CrCl <30 ml/minute) is not recommended. Another way to manage these agents is to define a more conservative approach and to recommend the same interruption period for all the NOACs. With this approach, interruption should be 4 days in all patients and, in some cases (elderly, severe renal insufficiency), the interruption should approach 5 days. Additional studies are needed to optimize perioperative management.Figure 1

Bottom Line: Due to the lack of good clinical studies involving adequate monitoring and reversal therapies, management requires knowledge and understanding of pharmacokinetics, renal function, drug interactions, and evaluation of the surgical bleeding risk.As a consequence, a multimodal approach should be taken which includes the administration of 25 to 50 U/kg 4-factor prothrombin complex concentrates or 30 to 50 U/kg activated prothrombin complex concentrate (FEIBA®) in some life-threatening situations.Finally, further studies are needed to clarify the ideal therapeutic intervention.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA. david.faraoni@childrens.harvard.edu.

ABSTRACT
Perioperative management of patients treated with the non-vitamin K antagonist oral anticoagulants is an ongoing challenge. Due to the lack of good clinical studies involving adequate monitoring and reversal therapies, management requires knowledge and understanding of pharmacokinetics, renal function, drug interactions, and evaluation of the surgical bleeding risk. Consideration of the benefit of reversal of anticoagulation is important and, for some low risk bleeding procedures, it may be in the patient's interest to continue anticoagulation. In case of major intra-operative bleeding in patients likely to have therapeutic or supra-therapeutic levels of anticoagulation, specific reversal agents/antidotes would be of value but are currently lacking. As a consequence, a multimodal approach should be taken which includes the administration of 25 to 50 U/kg 4-factor prothrombin complex concentrates or 30 to 50 U/kg activated prothrombin complex concentrate (FEIBA®) in some life-threatening situations. Finally, further studies are needed to clarify the ideal therapeutic intervention.

Show MeSH
Related in: MedlinePlus