title: The perioperative management of new direct oral anticoagulants: a question without answers.
abstract: New direct oral anticoagulant agents (DOAC) are currently licensed for thromboprophylaxis after hip and knee arthroplasty and for long-term 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.
authors.affiliation: Raquel Ferrandis Comes, Department of Anaesthesiogy and Critical Care, Hospital Clínic Universitari, Av Blasco Ibáñez, 17, 46010 Valencia, Spain, E-mail: raquelferrandis@gmail.com.
authors.forename: R
authors.initials: R
authors.lastname: Ferrandis
authors.forename: J
authors.initials: J
authors.lastname: Castillo
authors.forename: J
authors.initials: J
authors.lastname: de Andrés
authors.forename: C
authors.initials: C
authors.lastname: Gomar
authors.forename: A
authors.initials: A
authors.lastname: Gómez-Luque
authors.forename: F
authors.initials: F
authors.lastname: Hidalgo
authors.forename: J V
authors.initials: JV
authors.lastname: Llau
authors.forename: P
authors.initials: P
authors.lastname: Sierra
authors.forename: L M
authors.initials: LM
authors.lastname: Torres
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000776:Anesthesiology; D000925:Anticoagulants / Q000008:administration & dosage* / Q000737:chemistry; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D001562:Benzimidazoles / Q000008:administration & dosage; D000069604:Dabigatran; D005260:Female; D006470:Hemorrhage / Q000517:prevention & control*; D006487:Hemostasis; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D006801:Humans; D008297:Male; D009025:Morpholines / Q000627:therapeutic use; D061214:Patient Safety; D059035:Perioperative Period; D011720:Pyrazoles / Q000627:therapeutic use; D011728:Pyridones / Q000627:therapeutic use; D000069552:Rivaroxaban; D013876:Thiophenes / Q000627:therapeutic use; D013923:Thromboembolism / Q000517:prevention & control*; D015091:beta-Alanine / Q000008:administration & dosage / Q000031:analogs & derivatives
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D006495:Heparin, Low-Molecular-Weight; D009025:Morpholines; D011720:Pyrazoles; D011728:Pyridones; D013876:Thiophenes; D015091:beta-Alanine; C522181:apixaban; D000069552:Rivaroxaban; D000069604:Dabigatran