The AAST prospective observational multicenter study of the initial experience with reversal of direct oral anticoagulants in trauma patients

Emigh, Brent; Kobayashi, Leslie; Kopp, Miroslav; Daley, Mitch; Teal, Lindsey N.; Haan, James M.; Burlew, Clay Cothren; Nirula, Raminder; Moore, Forrest O.; Burruss, Sigrid; Kaminski, Stephen; Dunn, Julie; Carrick, Matthew M.; Schroeppel, Thomas J.; Thurston, Brian C; Quick, Jacob; Bosarge, Patrick L.; Brown, Carlos V R

doi:10.1016/j.amjsurg.2020.12.034

Cited by 11 publications

(12 citation statements)

References 30 publications

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“…Further, no outcome differences could be detected between pre-injury DOAC and VKA intake ( 146 , 147 ). In the AAST trial, DOAC reversal was not independently associated with mortality ( 148 ).…”

Section: Resultsmentioning

confidence: 99%

Coagulopathy management of multiple injured patients – a comprehensive literature review of the European guideline 2019

et al. 2022

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The European guideline on the management of trauma-induced major bleeding and coagulopathy summarises the most relevant recommendations for trauma coagulopathy management. The management of trauma-induced major bleeding should interdisciplinary follow algorithms which distinguish between life-threatening and non-life-threatening bleeding. Point-of-care viscoelastic methods (VEM) assist target-controlled haemostatic treatment. Neither conventional coagulation assays nor VEM should delay treatment in life-threatening trauma-induced bleeding. Adjustments may be rational due to local circumstances, including the availability of blood products, pharmaceuticals, and employees.

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Section: Resultsmentioning

confidence: 99%

Coagulopathy management of multiple injured patients – a comprehensive literature review of the European guideline 2019

et al. 2022

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“…8,21,22 Moreover, the limited available trauma literature suggests no mortality benefit from the use of drug-specific reversal agents in the setting of life-threatening head and abdominal injuries. 6 These factors strongly influence the current practice pattern in DOAC reversal and most likely account for the lack of use of drug-specific reversal agents in our study cohort.…”

Section: Discussionmentioning

confidence: 97%

“…In 2010, direct oral ACs (DOACs) were introduced for the treatment of AF, DVTs, and PEs. 6,7 Direct oral ACs offer clinical advantages over warfarin such as rapid onset/offset of action, fewer drug interactions and predictable pharmacokinetics without the need for routine laboratory monitoring. 6 Therefore, DOACs have become the preferred AC of choice over warfarin.…”

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confidence: 99%

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Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study

O’Meara

Zhang

Vesselinov

et al. 2023

J Trauma Acute Care Surg

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BACKGROUND:While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs). METHODS:This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis. RESULTS:Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups.After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality. CONCLUSION:Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use.

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“…1,2 Several case reports and publications report use of andexanet in trauma and surgery patients, but data are extremely sparse. 6,12,13,[15][16][17][18][19][20][21][22][23] Andexanet pharmacology, safety, and monitoring require careful consideration and remain undescribed in surgery patients. We present an assessment of each of these factors in a unique surgical case where the andexanet infusion was prolonged.…”

Section: Discussionmentioning

confidence: 99%

Case Report: Extended Duration Andexanet Alfa Infusion in a Surgical Trauma Patient

Philpott

Ernst

Makley

et al. 2022

Journal of Pharmacy Practice

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Background Andexanet alfa (andexanet) is the only FDA-approved medication for reversal of apixaban and rivaroxaban anticoagulation for life-threatening or uncontrolled bleeding. Infusion modifications may be required in surgical patients undergoing prolonged operative intervention but have not previously been described. Case Report A 78-year-old woman on rivaroxaban for atrial fibrillation was admitted to the trauma service for a mechanical fall, sustaining a T4 burst fracture with severe canal stenosis and spinal cord edema resulting in loss of strength and sensation in her legs. Clinically relevant rivaroxaban activity was verified with an elevated low molecular weight heparin anti-factor Xa assay, and laboratory confirmed coagulopathy was demonstrated by a prolonged prothrombin time, thromboelastography (TEG) R-time, and activated clotting time (ACT). The patient required urgent surgical intervention for spinal fixation. Given the expected prolonged duration of the procedure, standard dose andexanet was initiated with a prolonged infusion at half the standard rate during the operation. The procedure was successful and intraoperative TEGs demonstrated normalization of R-time and ACT throughout the procedure. The patient did not experience any complications postoperatively and successfully discharged to inpatient rehabilitation. Conclusion Modifications to the andexanet infusion may be required in surgical patients requiring rivaroxaban reversal for a prolonged procedure. Further data are needed to determine the optimal approach to infusion modification.

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The AAST prospective observational multicenter study of the initial experience with reversal of direct oral anticoagulants in trauma patients

Cited by 11 publications

References 30 publications

Coagulopathy management of multiple injured patients – a comprehensive literature review of the European guideline 2019

Coagulopathy management of multiple injured patients – a comprehensive literature review of the European guideline 2019

Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study

Case Report: Extended Duration Andexanet Alfa Infusion in a Surgical Trauma Patient

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