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Management of oral anticoagulants prior to emergency surgery or with major bleeding: A survey of perioperative practices in North America: Communication from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis.
Res Pract Thromb Haemost. 2020 May; 4(4):562-568.RP

Abstract

Background

There is limited information on real-world practice versus current clinical practice guidelines for oral anticoagulant reversal before emergency surgery.

Objective

To identify current practice/knowledge gaps for oral anticoagulant reversal emergency surgery among anesthesiologists.

Methods

A 22-question survey covering aspects of clinical practice relating to oral anticoagulant reversal was sent to American Society of Anesthesiology members with weekly reminders during data collection from October to December 2018.

Results

Responses were received from 2315 anesthesiologists of which 86% of respondents were United States based. Emergency surgery was defined as occurring within 4 hours of the decision to operate by 60% of respondents. Fresh frozen plasma (FFP) was used by 75% of respondents for vitamin K antagonist (VKA) reversal and by 54% for direct oral anticoagulant (DOAC) reversal in emergency surgery and 67% in major operative bleeding. Only 32% of institutions had emergency anticoagulant reversal protocols, and 54% of respondents selected an international normalized ration (INR) ratio goal for VKA reversal of ≤1.5. Only 13% initially consulted or coordinated management with hematologists, and the final decision regarding coagulation management was made by the respondent in 26% of cases. A coordinated approach with hematologists and cardiologists was reported by 64%, and over half (51%) required approval for prothrombin complex concentrate administration for emergency procedures.

Conclusions

Despite recommendations to the contrary, FFP is extensively used for emergency VKA and DOAC reversal. There is a clear need for institutions to develop guideline-informed recommendations/management algorithms based on input from medical professionals routinely involved in management of these patients.

Authors+Show Affiliations

Division of Cardiothoracic Anesthesiology and Critical Care Department of Anesthesiology Duke University School of Medicine Durham North Carolina.Hematology Division Department of Medicine Brigham and Women's Hospital Harvard Medical School Boston Massachusetts.Divisions of Hematology and Critical Care Department of Pediatrics University of Minnesota Minneapolis Minnesota.Department of Medicine McMaster University Hamilton ON Canada.Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill Hospital New York New York.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

32548554

Citation

Levy, Jerrold H., et al. "Management of Oral Anticoagulants Prior to Emergency Surgery or With Major Bleeding: a Survey of Perioperative Practices in North America: Communication From the Scientific and Standardization Committees On Perioperative and Critical Care Haemostasis and Thrombosis of the International Society On Thrombosis and Haemostasis." Research and Practice in Thrombosis and Haemostasis, vol. 4, no. 4, 2020, pp. 562-568.
Levy JH, Connors JM, Steiner ME, et al. Management of oral anticoagulants prior to emergency surgery or with major bleeding: A survey of perioperative practices in North America: Communication from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis. Res Pract Thromb Haemost. 2020;4(4):562-568.
Levy, J. H., Connors, J. M., Steiner, M. E., Douketis, J., & Spyropoulos, A. C. (2020). Management of oral anticoagulants prior to emergency surgery or with major bleeding: A survey of perioperative practices in North America: Communication from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis. Research and Practice in Thrombosis and Haemostasis, 4(4), 562-568. https://doi.org/10.1002/rth2.12320
Levy JH, et al. Management of Oral Anticoagulants Prior to Emergency Surgery or With Major Bleeding: a Survey of Perioperative Practices in North America: Communication From the Scientific and Standardization Committees On Perioperative and Critical Care Haemostasis and Thrombosis of the International Society On Thrombosis and Haemostasis. Res Pract Thromb Haemost. 2020;4(4):562-568. PubMed PMID: 32548554.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Management of oral anticoagulants prior to emergency surgery or with major bleeding: A survey of perioperative practices in North America: Communication from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis. AU - Levy,Jerrold H, AU - Connors,Jean M, AU - Steiner,Marie E, AU - Douketis,James, AU - Spyropoulos,Alex C, Y1 - 2020/03/02/ PY - 2020/01/04/received PY - 2020/01/09/revised PY - 2020/01/13/accepted PY - 2020/6/18/entrez PY - 2020/6/18/pubmed PY - 2020/6/18/medline KW - anticoagulants KW - antidotes KW - apixaban KW - bleeding KW - dabigatran KW - fresh frozen plasma KW - prothrombin complex concentrates KW - rivaroxaban KW - warfarin SP - 562 EP - 568 JF - Research and practice in thrombosis and haemostasis JO - Res Pract Thromb Haemost VL - 4 IS - 4 N2 - Background: There is limited information on real-world practice versus current clinical practice guidelines for oral anticoagulant reversal before emergency surgery. Objective: To identify current practice/knowledge gaps for oral anticoagulant reversal emergency surgery among anesthesiologists. Methods: A 22-question survey covering aspects of clinical practice relating to oral anticoagulant reversal was sent to American Society of Anesthesiology members with weekly reminders during data collection from October to December 2018. Results: Responses were received from 2315 anesthesiologists of which 86% of respondents were United States based. Emergency surgery was defined as occurring within 4 hours of the decision to operate by 60% of respondents. Fresh frozen plasma (FFP) was used by 75% of respondents for vitamin K antagonist (VKA) reversal and by 54% for direct oral anticoagulant (DOAC) reversal in emergency surgery and 67% in major operative bleeding. Only 32% of institutions had emergency anticoagulant reversal protocols, and 54% of respondents selected an international normalized ration (INR) ratio goal for VKA reversal of ≤1.5. Only 13% initially consulted or coordinated management with hematologists, and the final decision regarding coagulation management was made by the respondent in 26% of cases. A coordinated approach with hematologists and cardiologists was reported by 64%, and over half (51%) required approval for prothrombin complex concentrate administration for emergency procedures. Conclusions: Despite recommendations to the contrary, FFP is extensively used for emergency VKA and DOAC reversal. There is a clear need for institutions to develop guideline-informed recommendations/management algorithms based on input from medical professionals routinely involved in management of these patients. SN - 2475-0379 UR - https://www.unboundmedicine.com/medline/citation/32548554/Management_of_oral_anticoagulants_prior_to_emergency_surgery_or_with_major_bleeding:_A_survey_of_perioperative_practices_in_North_America:_Communication_from_the_Scientific_and_Standardization_Committees_on_Perioperative_and_Critical_Care_Haemostasis_and_Thrombosis_of_the_International_Society_on_Thrombosis_and_Haemostasis L2 - https://doi.org/10.1002/rth2.12320 DB - PRIME DP - Unbound Medicine ER -
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