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Updates in the perioperative and emergency management of non-vitamin K antagonist oral anticoagulants

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Abstract

Perioperative management of patients treated with the non-vitamin K antagonist oral anticoagulants is an ongoing challenge. Due to the lack of good clinical studies involving adequate monitoring and reversal therapies, management requires knowledge and understanding of pharmacokinetics, renal function, drug interactions, and evaluation of the surgical bleeding risk. Consideration of the benefit of reversal of anticoagulation is important and, for some low risk bleeding procedures, it may be in the patient’s interest to continue anticoagulation. In case of major intra-operative bleeding in patients likely to have therapeutic or supra-therapeutic levels of anticoagulation, specific reversal agents/antidotes would be of value but are currently lacking. As a consequence, a multimodal approach should be taken which includes the administration of 25 to 50 U/kg 4-factor prothrombin complex concentrates or 30 to 50 U/kg activated prothrombin complex concentrate (FEIBA®) in some life-threatening situations. Finally, further studies are needed to clarify the ideal therapeutic intervention.

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Abbreviations

CI:

Confidence interval

CrCl:

Creatinine clearance

NOAC:

Non-vitamin K antagonist oral anticoagulant

PCC:

Prothrombin complex concentrate

PT:

Prothrombin time

rFVIIa:

recombinant activated factor VII

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Acknowledgements

The authors are members of the 'Groupe d’Intérêt en Hémostase Périopératoire' (GIHP) Consists of Pierre Albaladejo, Samia Jebara, Annick Steib, Anne Godier, Gilles Pernod, Sylvain Belisle, Normand Blais, Fanny Bonhomme, Annie Borel-Derlon, Jeanne-Yvonne Borg, Jean-Luc Bosson, Jean-Philippe Collet, Emmanuel De Maistre, Philippe De Moerloose, Pierre Fontana, Yves Gruel, Joanne Guay, Yann Huet, Brigitte Ickx, Brigitte Jude, Dominique Lasne, Dan Longrois, Jean-François Hardy, Emmanuel Marret, Patrick Mismetti, Serge Motte, Nathalie Nathan, Nadia Rosencher, Charles Marc Samama, Laurence Jesel-Morel, Jean-Francois Schved, Sylvie Schlumberger, Pierre Sie, Sophie Susen, Philippe Van der Linden, André Vincentelli, Paul Zufferey, Ariel Cohen, Juan V. Llau Pitarch, Eric Vanbelle, Gregoire Legal, Sylvie Laporte, Thomas Pierre Lecompte, Yves Ozier, Philippe Nguyen, Stephanie Roullet, David Faraoni

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Authors and Affiliations

  1. Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, 02115, USA

    David Faraoni

  2. Department of Anesthesiology and Intensive Care, Duke University School of Medicine, Durham, NC, 27710, USA

    Jerrold H Levy

  3. Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, 38043, France

    Pierre Albaladejo

  4. Department of Anesthesiology and Intensive Care Medicine, Assistance Publique- Hôpitaux de Paris, Cochin University Hospital, Paris, 75181, France

    Charles-Marc Samama

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Correspondence to David Faraoni.

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Competing interests

DF declares no competing interests. JHL: advisory committees/research steering committees: CSL Behring, Boehringer-Ingelheim, Grifols, Janssen, Medicines Company, Octaphrama, Portola, and Roche. PA: grant money (from industry-related sources), Octapharma, CSL Behring, LFB: speaker’s fee from Bayer, Boehringer-Ingelheim, CSL Behring, Daichii Sankyo, LFB, Sanofi, B-Braun; advisory committees Bayer, BMS-Pfizer alliance, Boehringer-Ingelheim, Daichii-Sankyo; Primary Investigator Boehringer-Ingelheim. CMS: grant money (from industry-related sources), NovoNordisk, CSL Behring, LFB; Speaker’s fee from Abbott, AstraZeneca, Bayer, BMS, Boehringer-Ingelheim, Covidien, CSL Behring, Daichii, GSK, LFB, Lilly, Octapharma, Pfizer, Rovi, Sanofi; advisory committees AstraZeneca, Bayer, BMS, Boehringer-Ingelheim, Daichii-Sankyo, Fresenius-Kabi, GSK, Haemonetics, Lilly, Pfizer, Roche, Sanofi; Primary Investigator Bayer, BMS, Boehringer-Ingelheim, LFB, GSK, Haemonetics, Sanofi.

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Faraoni, D., Levy, J.H., Albaladejo, P. et al. Updates in the perioperative and emergency management of non-vitamin K antagonist oral anticoagulants. Crit Care 19, 203 (2015). https://doi.org/10.1186/s13054-015-0930-9

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