New guidelines for NOAC use in surgical patients

Restarting NOACs after surgery

The researchers said NOACs can be restarted at a therapeutic dose 24 hours after procedures that confer a low bleeding risk and 48 to 72 hours after procedures that confer a high bleeding risk, as long as adequate hemostasis has been achieved.

If patients have undergone procedures associated with immobilization, they should be given low-molecular-weight heparins 6 to 8 hours after surgery, once hemostasis has been achieved. Then, they can receive NOACs 48 to 72 hours after the procedure.

Managing bleeding complications

NOACs pose a lower risk of intracranial bleeding than warfarin, but they also confer an increased risk of gastrointestinal bleeding. If any bleeding occurs, physicians should enquire about the exact time and amount of the patient’s last NOAC dose.

“As NOACs have short elimination half-lives, time is the most important antidote,” Dr Lai and her colleagues noted.

If the bleeding is not life-threatening, withholding the NOAC and initiating standard supportive measures, such as fluid resuscitation and hemostatic measures, may be sufficient. Patients may receive red cell and platelet transfusions if necessary. And fresh-frozen plasma is appropriate as a plasma expander but not as a reversal agent.

If a patient is experiencing severe or life-threatening bleeding, physicians should withhold the NOAC and initiate standard supportive measures. But they should also try to reverse the anticoagulant effect with activated PCC (50 units/kg) or PCC (25 units/kg) in the case of rivaroxaban and hemodialysis in the case of dabigatran.