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Review
. 2019 Aug;46(4):282-293.
doi: 10.1159/000491400. Epub 2019 Jan 29.

NOACs in Anesthesiology

Donat R Spahn  1 , Jürg-Hans Beer  2 , Alain Borgeat  3 , Pierre-Guy Chassot  4 , Christian Kern  5 , François Mach  6 , Krassen Nedeltchev  7 , Wolfgang Korte  8
Affiliations
Review

NOACs in Anesthesiology

Donat R Spahn et al. Transfus Med Hemother. 2019 Aug.

Abstract

Background: Due to increasing use of new oral anticoagulants (NOACs), clinicians are faced more and more frequently with clinical issues related to these drugs.

Objective: The objective of this publication is to make practical suggestions for the perioperative management of NOACs as well as for their handling in overdoses and bleedings.

Recommendations: In elective surgery and creatinine clearance ≥ 50 ml/min, a NOAC should be discontinued 24-36 h before the intervention, and even earlier in case of reduced kidney function. In emergency interventions that cannot be delayed, the management is dependent on the NOAC plasma levels. With levels ≤ 30 ng/ml, surgery can be performed. With levels >30 ng/ml, reversal agents should be considered. In low bleeding risk surgery, NOACs can be re-started 24 h after the intervention, which is prolonged to 48-72 h after surgery with high bleeding risk. In case of NOAC overdose and minor bleedings, temporary discontinuation and supportive care are usually sufficient to control the situation. In severe or life-threatening bleedings, nonspecific and specific reversal agents should be considered.

Keywords: Anesthesiology; Direct oral anticoagulants; New oral anticoagulants; Thrombin inhibitor; Xa antagonist.

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Conflict of interest statement

DRS: Dr. Spahn's academic department is receiving grant support from the Swiss National Science Foundation, Berne, Switzerland, the Ministry of Health (Gesundheitsdirektion) of the Canton of Zurich, Switzerland, for Highly Specialized Medicine, the Swiss Society of Anesthesiology and Reanimation (SGAR), Berne, Switzerland, the Swiss Foundation for Anesthesia Research, Zurich, Switzerland, CSL Behring, Berne, Switzerland, Vifor SA, Villars-sur-Glâne, Switzerland. Dr. Spahn is co-chair of the ABC-Trauma Faculty, sponsored by unrestricted educational grants from Novo Nordisk Health Care AG, Zurich, Switzerland, CSL Behring GmbH, Marburg, Germany, LFB Biomédicaments, Courtaboeuf Cedex, France and Octapharma AG, Lachen, Switzerland. Dr. Spahn has received honoraria or travel support for consulting or lecturing from: Danube University of Krems, Austria, US Department of Defense, Washington, USA, European Society of Anesthesiology, Brussels, BE, Korea, Korean Society for Patient Blood Management, Seoul, Korea, Korean Society of Anesthesiologists, Seoul, Baxter AG, Volketswil, Switzerland, Baxter S.p.A., Roma, Italy, Bayer AG, Zürich, Switzerland, Bayer Pharma AG, Berlin, Germany, B. Braun Melsungen AG, Melsungen, Germany, Boehringer Ingelheim GmbH, Basel, Switzerland, Bristol-Myers-Squibb, Rueil-Malmaison Cedex, France and Baar, Switzerland, CSL Behring GmbH, Hattersheim am Main, Germany and Berne, Switzerland, Celgene International II Sàrl, Couvet, Switzerland, Curacyte AG, Munich, Germany, Daiichi Sankyo AG, Thalwil, Switzerland, GlaxoSmithKline GmbH & Co. KG, Hamburg, Germany, Haemonetics, Braintree, MA, USA, Instrumentation Laboratory (Werfen), Bedford, MA, USA, LFB Biomédicaments, Courtaboeuf Cedex, France, Merck Sharp & Dohme, Kenilworth, NJ, USA, Octapharma AG, Lachen, Switzerland, Organon AG, Pfäffikon/SZ, Switzerland, PAION Deutschland GmbH, Aachen, Germany, Pharmacosmos A/S, Holbaek, Denmark, Photonics Healthcare B.V., Utrecht, Netherlands, Roche Diagnostics International Ltd, Reinach, Switzerland, Roche Pharma AG, Reinach, Switzerland, Sarstedt AG & Co., Sevelen, Switzerland and Nümbrecht, Germany, Schering-Plough International, Inc., Kenilworth, NJ, USA, Tem International GmbH, Munich, Germany, Verum Diagnostica GmbH, Munich, Germany, Vifor Pharma, Munich, Germany, Vienna, Austria and Villars-sur-Glâne, Switzerland, Vifor (International) AG, St. Gallen. JHB: Grant support from SNF and Swiss Heart Foundation, grant support, travel support, honoraria for consulting or lecturing from Bayer, Boehringer Ingelheim, Bristol-Myers-Squibb, Daiichi Sankyo, Pfizer, Astra Zeneca. AB: travel support, honoraria for consulting or lecturing from Bayer, Boehringer Ingelheim, Bristol-Myers-Squibb, Daiichi Sankyo, Pfizer PGC: travel support, honoraria for consulting or lecturing from Bayer, Boehringer Ingelheim, Bristol-Myers-Squibb, Daiichi Sankyo. CK: travel support, honoraria for consulting or lecturing from Bayer, Boehringer Ingelheim, Bristol-Myers-Squibb, Daiichi Sankyo. FM: travel support, honoraria for consulting or lecturing from Bayer, Boehringer Ingelheim, Bristol-Myers-Squibb, Daiichi Sankyo. KN: travel support, honoraria for consulting or lecturing from Bayer, Boehringer Ingelheim, Bristol-Myers-Squibb, Daiichi Sankyo. WK: travel support, honoraria for consulting or lecturing from Bayer, Boehringer Ingelheim, Bristol-Myers-Squibb, Daiichi Sankyo.

Figures

Fig. 1
Fig. 1
Emergency intervention schema, adapted after [54].
See this image and copyright information in PMC

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