title: [Management of major bleeding complications and emergency surgery in patients on long-term treatment with direct oral anticoagulants, thrombin or factor-Xa inhibitors. Proposals of the Working Group on Perioperative Haemostasis (GIHP) - March 2013].
abstract: New direct oral anticoagulants (NOAC), inhibitors of factor IIa or Xa, are expected to be widely used for the treatment of venous thromboembolic disease, or in case of atrial fibrillation. Such anticoagulant treatments are known to be associated with haemorrhagic complications. Moreover, it is likely that such patients on long-term treatment with NOAC will be exposed to emergency surgery or invasive procedures. Due to the present lack of experience in such conditions, we cannot make recommendations, but only propose management for optimal safety as regards the risk of bleeding in such emergency conditions. In this article, only dabigatran and rivaroxaban were discussed. For emergency surgery at risk of bleeding, we propose to dose the plasmatic concentration of drug. Levels inferior or equal to 30ng/mL for both dabigatran and rivaroxaban, should enable the realization of a high bleeding risk surgery. For higher concentration, it was proposed to postpone surgery by monitoring the evolution of the drug concentration. Action is then defined by the kind of NOAC and its concentration. If the dosage of the drug is not immediately available, proposals only based on the usual tests, PT and aPTT, also are presented. However, these tests do not really assess drug concentration or bleeding risk. In case of severe haemorrhage in a critical organ, it is proposed to reduce the effect of anticoagulant therapy using a nonspecific procoagulant drug (activated prothrombin concentrate, FEIBA, 30-50U/kg, or non-activated 4-factors prothrombin concentrates 50U/kg). For any other type of severe haemorrhage, the administration of such a procoagulant drug, potentially thrombogenic in these patients, will be discussed regarding concentration of NACO and possibilities for mechanical haemostasis.
authors.affiliation: Unité de médecine vasculaire, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France; UJF-Grenoble 1/CNRS TIMC-IMAG UMR 5525/Themas, 38041 Grenoble, France.
authors.forename: G
authors.initials: G
authors.lastname: Pernod
authors.forename: P
authors.initials: P
authors.lastname: Albaladejo
authors.forename: A
authors.initials: A
authors.lastname: Godier
authors.forename: C M
authors.initials: CM
authors.lastname: Samama
authors.forename: S
authors.initials: S
authors.lastname: Susen
authors.forename: Y
authors.initials: Y
authors.lastname: Gruel
authors.forename: N
authors.initials: N
authors.lastname: Blais
authors.forename: P
authors.initials: P
authors.lastname: Fontana
authors.forename: A
authors.initials: A
authors.lastname: Cohen
authors.forename: J V
authors.initials: JV
authors.lastname: Llau
authors.forename: N
authors.initials: N
authors.lastname: Rosencher
authors.forename: J F
authors.initials: JF
authors.lastname: Schved
authors.forename: E
authors.initials: E
authors.lastname: de Maistre
authors.forename: M M
authors.initials: MM
authors.lastname: Samama
authors.forename: P
authors.initials: P
authors.lastname: Mismetti
authors.forename: P
authors.initials: P
authors.lastname: Sié
mesh_terms: D000925:Anticoagulants / Q000097:blood / Q000627:therapeutic use*; D001562:Benzimidazoles / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D000069604:Dabigatran; D004630:Emergencies; D004632:Emergency Medical Services / Q000379:methods*; D065427:Factor Xa Inhibitors; D006470:Hemorrhage / Q000188:drug therapy / Q000628:therapy*; D006487:Hemostasis / Q000502:physiology*; D006801:Humans; D009025:Morpholines / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D019990:Perioperative Care / Q000379:methods*; D000069552:Rivaroxaban; D013514:Surgical Procedures, Operative; D013876:Thiophenes / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D013917:Thrombin / Q000037:antagonists & inhibitors*; D015091:beta-Alanine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D065427:Factor Xa Inhibitors; D009025:Morpholines; D013876:Thiophenes; D015091:beta-Alanine; D000069552:Rivaroxaban; D013917:Thrombin; D000069604:Dabigatran
keywords: Anti-IIa; Anti-Xa; Anticoagulants oraux; Chirurgie; Emergency; Haemorrhage; Hémorragie; Oral anticoagulant; Reversal; Réversion; Surgery; Urgence