Management of the Trauma Patient on Direct Oral Anticoagulants

Abstract

Anesthesiologists managing traumatically injured patients are seeing an increased incidence of patients on direct oral anticoagulants (DOACs). Management of these patients requires an understanding of the pharmacology and pharmacodynamics of these agents in the perioperative setting. With limited reversal options, what are the best options for managing these often complex patients? The reversal agent for dabigatran, idarucizumab, can be useful in the setting of severe hemorrhage. The role of prothrombin complex concentrates is less clear but continues to be recommended in most published guidelines. Management of the DOAC-associated bleeding in the trauma patient requires a stepwise approach taking the severity of bleeding and urgency of surgery/procedures into consideration as well as hemodynamic stability and mortality risk. Frequently, a conservative approach that allows for a drop in plasma DOAC levels is the best option for the patient with minimal to no bleeding. The use of specific reversal agents is limited to dabigatran, but other agents are on the horizon.