Haemodialysis before emergency surgery in a patient treated with dabigatran

Abstract

Novel oral anticoagulants (NOAs) which directly inhibit thrombin (dabigatran) or factor Xa (rivaroxaban and apixaban) have recently been developed. We report the first case of perioperative management of a patient treated with dabigatran requiring haemodialysis before emergency surgery. A 62-yr-old woman visited the emergency department for a left bi-malleolar ankle fracture; she had a past medical history of severe ischaemic cardiomyopathy, alcoholic cirrhosis Child B, and moderate chronic renal insufficiency. The patient was treated with dabigatran for a left ventricular aneurysm with thrombus. Cutaneous manifestation of a voluminous haematoma required emergency surgery. Blood tests revealed dabigatran anticoagulant activity of 123 ng ml(-1) (therapeutic values: 85-200 ng ml(-1)), activated partial thromboplastin time of 63 s, and a prothrombin ratio of 68%, indicating that dabigatran disturbed coagulation. We decided to perform emergency haemodialysis before surgery. After 2 h, the anticoagulant activity of dabigatran was 11 ng ml(-1), allowing surgery. Surgery proceeded without any problems and the postoperative period was unremarkable. This case highlights the difficulties for the anaesthesiologist regarding emergency perioperative management of patients treated with NOAs and confirms the efficacy of haemodialysis in cases of dabigatran treatment. NOAs should be prescribed with caution, especially for patients with renal or hepatic disease, at least as long as no antagonist is available. In cases of deferred operative urgency in haemodynamically stable patients treated with dabigatran, haemodialysis should be considered to reverse dabigatran's anticoagulant effects.

Hemodialysis for the treatment of dabigatran‐associated bleeding: a case report and systematic review

“…Thirty articles were excluded by full‐text review. Consequently, 22 studies were included in the review, involving 35 individual patient cases. The reasons for exclusion are summarized in Fig.…”

“…Subgroup analysis of the RE‐LY trial showed that the risk of major bleeding in patients aged ≥ 75 years who received dabigatran 110 mg twice daily was higher than that in those aged < 75 years (4.43% versus 1.89%) . Similarly, among patients who received dabigatran 150 mg twice daily, the risk of major bleeding was higher in patients aged ≥ 75 years than in those aged < 75 years (5.10% versus 2.12%) . Pharmacokinetic and pharmacodynamic data for the healthy elderly subjects (aged 65–87 years) were found to be predictable and reproducible.…”

Enhanced elimination of dabigatran: Identifying the appropriate patient for the use of continuous venovenous hemodialysis instead of intermittent hemodialysis—A simulation analysis

“…It can be viewed as the consensus that IHD is the most adequate and potent way for the accelerated elimination of dabigatran . The effectiveness of hemodialysis is illustrated in a case report by Esnault et al on a patient who required emergency surgery on stable dabigatran treatment. A dabigatran concentration of 123 ng/mL corresponded to an activated partial thromboplastin time of 63 seconds, indicating dabigatran activity.…”

Dabigatran anticoagulation and Stanford type A aortic dissection: lethal coincidence

“…In the context of the limited treatment options to overcome bleeding on dabigatran anticoagulation, preoperative haemodialysis and delaying the intervention even for a classic emergency like a type A aortic dissection should be considered until anti‐factor IIa levels of dabigatran are below the therapeutic levels, and thrombin clotting time is normalized. Continuous haemodialysis may be necessary to maintain low anti‐factor IIa levels …”