Managing new oral anticoagulants in the perioperative and intensive care unit setting

Area of Science:

• Anesthesiology and Perioperative Medicine
• Cardiology
• Hematology

Background:

• Novel oral anticoagulants (NOACs) are increasingly used for thromboprophylaxis and stroke prevention in atrial fibrillation.
• Managing patients on NOACs in the perioperative setting presents unique challenges, particularly regarding bleeding risk and management.
• NOACs include direct Factor Xa inhibitors (rivaroxaban, apixaban) and direct thrombin inhibitors (dabigatran).

Purpose of the Study:

• To review current data on managing bleeding complications associated with NOACs.
• To discuss strategies for perioperative management of patients on NOACs.
• To highlight the need for further research into NOAC reversal agents.

Main Methods:

• Literature review of available data on NOAC-related bleeding management.
• Summary of current clinical practices and in vitro study findings.
• Analysis of renal function's role in NOAC elimination.

Main Results:

• Discontinuation of NOACs before elective surgery is crucial, with renal function being a key factor.
• Hemodialysis is a potential treatment for dabigatran-related bleeding.
• Prothrombin complex concentrates show potential utility in managing rivaroxaban-related bleeding based on in vitro data.

Conclusions:

• Effective management of bleeding in patients on NOACs requires consideration of anticoagulant properties and renal function.
• Specific reversal strategies are emerging, such as hemodialysis for dabigatran and prothrombin complex concentrates for rivaroxaban.
• Further clinical trials are essential to establish definitive reversal methods for NOAC-associated bleeding.