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Perioperative Management of Patients Receiving New Anticoagulants

[ Vol. 25 , Issue. 19 ]

Author(s):

Massimo Lamperti*, Andrey Khozenko and Arun Kumar   Pages 2149 - 2157 ( 9 )

Abstract:


There is an increased use of oral anticoagulants for the prevention of venous and arterial thrombosis. Vitamin-K antagonists have been used for decades as the main oral anticoagulants but they have the draback a complex therapeutic management, slow onset of action and by a different oral intake caused by dietary vitamin K intake. New non-vitamin K antagonist oral anticoagulants (NOACs) have been developed to overcome the limitations of warfarin. Their management is easier as it requires a fixed daily dose without coagulation monitoring. Although their therapeutic profile is safe, proper attention should be paid in case of unexpected need for the reversal of their coagulation effect and in case a patient needs to have a scheduled surgery. For non-acute cardiac surgery, discontinuation of NOACs should start at least 48 hours prior surgery. Intracranial bleedings associated with NOACs are less dangerous comparing to those warfarin-induced. NOACs need to be stopped ≥24 hours in case of elective surgery for low bleeding-risk procedures and ≥48 hours for high bleeding-risk surgery in patients with normal renal function and 72 hours in case of reduced CrCl < 80. The therapy with NOACs should be resumed from 48 to 72 hours after the procedure depending on the perceived bleeding, type of surgery and thrombotic risks. There are some available NOAC reversal agents acting within 5 to 20 minutes. In case of lack of reversal agent, adequate diuresis, renal replacement therapy and activated charcoal in case of recent ingestion should be considered.

Keywords:

New oral anticoagulants, reversals, management, arterial thrombosis, cardiac surgery, activated charcoal, intracranial bleedings.

Affiliation:

Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi



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