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EDUCATION IN THE MANAGEMENT OF BLEEDING

A practical, evidence-based guide for front-line physicians on how to Treat the Bleed

How do I manage a patient taking a DOAC before emergency/urgent surgery?

DOAC Figure Q6

Reversal of the patient's DOAC may be needed for those who require an emergency surgery (<8-12 h, e.g., intracranial bleed, ruptured viscus, cardiac tamponade), urgent surgery (<24 h, e.g., hip fracture repair, acute cholecystitis), or invasive procedure that cannot be delayed.

Obtain the following information:

  • Which DOAC?
  • What dose?
  • When was the last dose?
  • Most recent creatinine?
  • Is it a major surgery – high risk of bleeding or severe consequences of bleeding? If Yes
    • How long can the surgery safely be delayed? – Necessary within 24 h? If Yes
      • Assay to measure DOAC levels (if available?) ( See question #2)
      • Estimate creatinine clearance (eCrCl) using Cockroft-Gault formula

Dabigatran

  • If thrombin time is normal or dilute thrombin time (Hemoclot®) <50 ng/mL – OK to operate
  • If dilute thrombin time unavailable – use timing of last dose and eCrCl to determine presence of drug – idarucizumab can effectively reverse the anticoagulant effect of dabigatran if needed ( See question #3):

Last Dose

eCrCl >50mL/min

eCrCl 30-50mL/min

eCrCl <30mL/min

<48 h ago

Idarucizumab 5 g

Idarucizumab 5 g

Idarucizumab 5 g

48-96 h ago

OK to operate

Idarucizumab 5 g

Idarucizumab 5 g

96-144 h ago

OK to operate

OK to operate

Idarucizumab 5 g

Apixaban, edoxaban, or rivaroxaban

  • If anti-Xa level calibrated for the specific DOAC is <50 ng/mL – OK to operate
  • If anti-Xa activity assay unavailable, use timing of last dose and eCrCl to determine presence of drug. PCCs 2000 IU is likely the best therapy without a specific reversal agent (andexanet alfa not commonly available in Canada)  ( See question #3):

Last Dose

eCrCl >50mL/min

eCrCl 30-50mL/min

eCrCl <30mL/min

<48 h ago

PCC 2000 units*

PCC 2000 units*

PCC 2000 units*

48-96 h ago

OK to operate

OK to operate

PCC 2000 units*

96-144 h ago

OK to operate

OK to operate

OK to operate

*No clinical evidence

Or use the electronic tool ( Perioperative Anticoagulant Management Algorithm).

For guidance on the perioperative management of patients taking a DOAC before an elective surgery/procedure, please visit the following Thrombosis Canada guide.

References:

  1. Cuker A, Burnett A, Triller D, et al. Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum. Am J Hematol. 2019;94:697-709.
  2. Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med. 2019;179:1469-1478.
  3. Macle L, Cairns JA, Andrade JG, et al. The 2014 Atrial Fibrillation Guidelines Companion: A Practical Approach to the Use of the Canadian Cardiovascular Society Guidelines. Can J Cardiol. 2015;31:1207-1218.
  4. Shaw JR, Woodfine JD, Douketis J, et al. Perioperative interruption of direct oral anticoagulants in patients with atrial fibrillation: A systematic review and meta-analysis. Res Pract Thromb Haemost. 2018;2:282-290.
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A practical, evidence-based guide for front-line physicians on how to treat acquired bleeding