Management of oral anticoagulants prior to emergency surgery or with major bleeding: A survey of perioperative practices in North America: Communication from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis

Abstract

Background There is limited information on real‐world practice versus current clinical practice guidelines for oral anticoagulant reversal before emergency surgery. Objective To identify current practice/knowledge gaps for oral anticoagulant reversal emergency surgery among anesthesiologists. Methods A 22‐question survey covering aspects of clinical practice relating to oral anticoagulant reversal was sent to American Society of Anesthesiology members with weekly reminders during data collection from October to December 2018. Results Responses were received from 2315 anesthesiologists of which 86% of respondents were United States based. Emergency surgery was defined as occurring within 4 hours of the decision to operate by 60% of respondents. Fresh frozen plasma (FFP) was used by 75% of respondents for vitamin K antagonist (VKA) reversal and by 54% for direct oral anticoagulant (DOAC) reversal in emergency surgery and 67% in major operative bleeding. Only 32% of institutions had emergency anticoagulant reversal protocols, and 54% of respondents selected an international normalized ration (INR) ratio goal for VKA reversal of ≤1.5. Only 13% initially consulted or coordinated management with hematologists, and the final decision regarding coagulation management was made by the respondent in 26% of cases. A coordinated approach with hematologists and cardiologists was reported by 64%, and over half (51%) required approval for prothrombin complex concentrate administration for emergency procedures. Conclusions Despite recommendations to the contrary, FFP is extensively used for emergency VKA and DOAC reversal. There is a clear need for institutions to develop guideline‐informed recommendations/management algorithms based on input from medical professionals routinely involved in management of these patients.

A physician survey of perioperative neuraxial anesthesia management in patients on a direct oral anticoagulant

“…Previous studies that assessed physician practices for perioperative anticoagulant management addressed general perioperative management in unselected patients, 21,22,24 focused on patients having cardiac device implantation 23 or dermatologic procedures, 20 addressed the type of clinician managing perioperative anticoagulation, 25 or only assessed management in patients who required emergency surgery 26 . The present study is the first, to our knowledge, to address perioperative DOAC management in an important high‐risk patient group undergoing a high‐bleed‐risk surgery/any neuraxial anesthesia.…”

Application of fresh frozen plasma transfusion in the management of excessive warfarin-associated anticoagulation

“…Hence, it is rational to conclude that FFP is still widely recommended for emergency reversal vitamin K antagonists and oral anticoagulants. 19 2.2.2. Emergency presurgical anticoagulant reversal.. FFP reversal of warfarin overdose is still widely used prior to emergency surgery, but postoperative complications and patient outcomes associated with it remain controversial.…”

“…Hence, it is rational to conclude that FFP is still widely recommended for emergency reversal vitamin K antagonists and oral anticoagulants. 19 …”

Andexanet Alfa Use in Cardiac Surgical Patients: A Xa Inhibitor and Heparin Reversal Agent

“…A recent survey of anesthesiologist management of oral anticoagulants prior to emergency surgery or with major bleeding reported, FFP was used by 75% of respondents for vitamin K antagonist reversal and by 54% for DOAC reversal in emergency surgery and 67% in major operative bleeding. 11 Only 32% of institutions had emergency anticoagulant reversal protocols. Specific considerations for the preoperative management of DOAC-treated patients include pharmacokinetics of the particular drug, renal function, and specific considerations regarding whether the surgery requires emergency intervention or is elective, and the particular risk of thrombosis and bleeding of the individual surgical procedure.…”