Oral Anticoagulants: Management of Elective and Emergency Surgery

Abstract

In most patients, oral anticoagulation is performed with vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC). Because of a long half-life, VKA are dosed by measuring INR. In standard cases coagulation tests for NOAC are not necessary; application is performed in a fixed dose. Special coagulation tests like anti-Xa activity (for factor Xa inhibitors: apixaban, edoxaban, rivaroxaban) and diluted thrombin time (for dabigatran) are available. At this time, no cut-off values are validated which show a higher risk of intra- and postoperative bleeding. For elective surgery, VKA are bridged by parenteral anticoagulation (e.g. low molecular weight heparin), NOAC are discontinued perioperative. Also, neuraxial anesthesia techniques can be performed with a proper time interval between last intake of a NOAC and puncture. If required, a transition from NOAC to parenteral anticoagulation can be made. Severe bleeding complications can be treated for VKA and NOAC as well by application of prothrombin complex concentrate. A specific antidote to dabigatran is available.