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):

*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.