title: [Perioperative anticoagulation with NOAC using the example of rivaroxaban].
abstract: Recent findings require an update of earlier recommendations on the perioperative management of non Vitamin K antagonist oral anticoagulants (NOAC).
  
  
  
  The present position paper summarises the outcomes of an expert panel discussion.
  
  
  
  Based on the pharmacokinetic profile of rivaroxaban, a preoperative interruption of 24-72 hours is recommended depending on the patient's renal function, as well as individual and surgery-related bleeding risks. Similar NOAC-free intervals are recommended for patients with epidural catheters. Elective surgery should be delayed accordingly. A low molecular weight heparin (LMWH) "bridging" (in fact "switching") should be avoided because of an increased bleeding risk. Six to 8 hours after the intervention rivaroxaban can be re-initiated or, in case of more extensive interventions or an increased bleeding risk, after 24-72 hours; if necessary this interval could by bridged with LMWH, e. g. if the thromboembolic risk is considered high. In case of emergency surgery with a rivaroxaban pause of less than 9 hours, one should be prepared for a bleeding management including the use of prothrombin concentrate (PCC). Coagulation tests have no value for predicting perioperative bleeding, in contrast to a standardised bleeding history. As an overall estimate, the PT (Quick) can be determined with a suitable reagent. Currently, rivaroxaban-specific measurements of anti Xa levels are available at few specialised centres only. Moderate to severe haemorrhages can usually be managed by temporary interruption of rivaroxaban in conjunction with local and general haemostatic measures. Life-threatening bleeding events require a specific haemostasis management including the administration of PCC; these events are rare and usually have a favourable prognosis, except for intracranial haemorrhages.
authors.affiliation: Gerinnungsambulanz mit Hämophiliezentrum im ambulanten Gesundheitszentrum (AGZ), Charité - Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, Durchgang Luisenstr. 13, 10117, Berlin, Deutschland. juergen.koscielny@charite.de.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Koscielny
authors.affiliation: Klinik für Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Vivantes Klinikum im Friedrichshain, Berlin, Deutschland.
authors.forename: Christian
authors.initials: C
authors.lastname: von Heymann
authors.affiliation: Klinikum Darmstadt GmbH, Klinik für Gefäßmedizin - Angiologie, Gefäßzentrum Darmstadt, Darmstadt, Deutschland.
authors.forename: Rupert
authors.initials: R
authors.lastname: Bauersachs
authors.affiliation: Sana Klinikum Offenbach, Offenbach, Deutschland.
authors.forename: Patrick
authors.initials: P
authors.lastname: Mouret
authors.affiliation: Klinik für Kardiologie, Herzzentrum Klinikum Oldenburg, Oldenburg, Deutschland.
authors.forename: Matthias
authors.initials: M
authors.lastname: Antz
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D006470:Hemorrhage / Q000188:drug therapy; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D006801:Humans; D019990:Perioperative Care; D000069552:Rivaroxaban / Q000627:therapeutic use*; D013923:Thromboembolism / Q000188:drug therapy
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D000069552:Rivaroxaban
keywords: NOAC; anticoagulation; perioperative management; rivaroxaban