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

Area of Science:

• Pharmacology
• Anesthesiology
• Neurosurgery

Background:

• Andexanet alfa is the sole FDA-approved reversal agent for apixaban and rivaroxaban.
• Its use in surgical patients requiring prolonged operative intervention necessitates understanding potential infusion modifications.
• Limited data exists on adjusting andexanet alfa infusion rates during extended surgical procedures.

Observation:

• A 78-year-old female on rivaroxaban presented with a T4 burst fracture requiring urgent spinal fixation.
• Preoperative assessment confirmed clinically relevant rivaroxaban activity and coagulopathy.
• A modified andexanet alfa infusion protocol (standard dose with prolonged infusion at half rate) was administered due to the anticipated long surgical duration.

Findings:

• The modified andexanet alfa infusion successfully facilitated the prolonged spinal surgery.
• Intraoperative thromboelastography (TEG) demonstrated normalization of R-time and activated clotting time (ACT) throughout the procedure.
• The patient experienced no intraoperative or postoperative complications and was discharged to rehabilitation.

Implications:

• Modified andexanet alfa infusion strategies may be crucial for managing anticoagulation reversal in complex surgical cases.
• This case highlights a potential approach for optimizing andexanet alfa administration during lengthy interventions.
• Further research is warranted to establish definitive guidelines for andexanet alfa infusion modifications in surgical settings.