3 Managing New Anticoagulants in the Perioperative Period

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Elective procedures requiring neuraxial
anesthesia receiving NOC

 DELAY if:
1. A thrombotic event (VTE, MI, TIA, or stroke) has occurred

within the previous 3 months
2. A major hemorrhage, (decrease in Hgb by 2GM/dl),

transfusion of 2 units of PRBCs, or bleeding into an organ
has occurred within previous 3 months
3. Patient is pregnant or < 6 weeks post partum

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Neuraxial Anesthesia

 A-fib, high risk for thrombosis, CHF, HTN, DM, vascular disease, previous
thromboembolism

 Discontinuation based on half-life

 Recommendation = 2 to 3 half-lives (30 - 45 hrs)

 Leaves some residual coagulation for prevention of VTE

 Conservative approach = 5-6 half-lives (3-5 days), may bridge with LMW
heparin

Half-lives % drug in circulation

1 50 53

2 25

3 12.5

4 6.25

5 3.1

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6 1.6

Prolonged half-lives

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Safety measures

 Avoid multiple attempts at catheter
insertion

 Stop if excessive bleeding occurs
 Close follow-up with heightened awareness

for bleeding complications

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Resuming NOACs

Recommendation is 24 – 48 hours after the procedure or catheter removal

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Interventional Spine and Pain procedures

 American Society of Regional and Pain Medicine

 Communicate with other providers – clear history of risk
 Chronic pain and stress = hypercoaguability
 High risk vs low risk procedures
 Fragility of epidural veins increases with age

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Pain procedures classification according to the
potential risk for serious bleed

HI • SCS trial and implant
• Intrathecal implant with pump
• Vertebroplasty, kyphoplasty

MOD • Interlaminar ESI
• Transforaminol ESI
• Paravertebral blocks
• Intradiscal procedures
• Sympathetic blocks

LOW • Peripheral nerve blocks
• Joint injections
• Trigger point injections
• SI injections

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Regional anesthesia

 American Society of Regional Anesthesia
 Based on half-life
 5 half-lives between stopping DOAC and performing
medium or high risk pain procedures

1. Dabigatran – 4-5 days
2. Rivaroxaban and apixaban – 3 -5 days

 Restart 24 hours

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My crush!!

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References

 Dubois, V., Dincq, A., Douxfils, J., Icxk, B. Samama, J.D., Gourdin, M.,
Chatelain, B. Mullier, F. & Lessire, S. (2017). Perioperative management of
patients on direct oral coagulants. Thrombosis Journal, 15(4).

 Christos, S. & Naples, R. (2016) Anticoagulation reversal and treatment
strategies in major bleeding: Update 2016. Western Journal of Emergency
Medicine. 17(3)

 Naroz, S, Benzon, H, Provenzano, D., Buvvanesuran, A., De Andres, A., Deer,
T., Rauk, R. & Huntoon, M. (2015). Interventional Spine and Pain Procedures
in Patients on Antiplatelet and Anticoagulant Medications. Regional
Anesthesia and Pain Medicine 40(3)

 Shaikh, S., Kuman, R.V., Hegade, G. & Marutheesh, M. (2017). Perioperative
Considerations and management of patients receiving anticoagulants.
Anesthesia Essays and Research, 11(1) 10-16,

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Thank you!!!

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