Drug Management of Direct Oral Anticoagulants for an Urgent Invasive Procedure: Contribution of Thoracic Ultrasound - Case Report

Abstract

Introduction: Direct oral anticoagulants (DOA) are recent drugs prescribed for their anticoagulant properties. When an invasive procedure is planned for a patient under DOA, the challenge for the anaesthetist is to assess the risk of bleeding and thromboembolism secondary to the medication withdrawal. In certain situations, ultrasound, with its advantages of guidance and location, is an important tool that can reduce the peri-procedural bleeding risk. Method: We illustrate this problem with this clinical case. Observation: This is an 18-year-old female patient with a history of recent deep vein thrombosis treated with direct oral anticoagulants in an underlying pulmonary tuberculosis condition under treatment; received in the intensive care unit for management of respiratory distress due to a hydro-pneumothorax confirmed on pleuropulmonary ultrasound. Amain this urgent indication for thoracic drainage, the patient benefited from a decision by the referral team to withdraw the DOAs for 3 days, a relay with curative LMWH, an exsufflation of the pneumothorax and an evacuation puncture of the effusion under ultrasound guidance and location. Chest drainage was performed successfully and uneventfully after 3 days of DOA withdrawal. Conclusion: When an invasive procedure has to be performed in the emergency department or when the thromboembolic risk is very high, validated strategies for the peri-procedural management of DOAs have not been the subject of consensus. Our case-report highlighted the value of thoracic ultrasound in the intensive care unit, which facilitates the performance of minimally traumatic procedures in the emergency department. This tool allows to postpone a procedure of bleeding risk while promoting good drug management.