Summary
The worldwide increase in the aging population and the associated increase in the
prevalence of atrial fibrillation and venous thromboembolism as well as the widespread
use of direct oral anticoagulants (DOAC) have resulted in an increase of the need
for the management of bleeding complications and emergency operations in this group
of patients, in clinical practice. When severe bleeding occurs, general assessment
should include evaluation of the bleeding site, onset and severity of bleeding, renal
function and concurrent medications with focus on antiplatelet drugs and nonsteroidal
anti-inflammatory drugs (NSAID). The last intake of the DOAC and its residual concentration
are also relevant. The site of bleeding should be immediately localized, anticoagulation
should be interrupted, local measures to stop bleeding should be taken. Immediate
reversal of the antithrombotic effect may be indicated. If relevant residual DOAC-concentrations
are expected and surgery cannot be postponed, prothrombin complex concentrate (PCC)
and/ or a specific antidote should be given. As a specific antidote for dabigatran,
idarucizumab is available, while andexanet alfa, an antidote for the reversal of inhibitors
of coagulation factor Xa, has been approved in May 2018 for clinical use only in the
USA.
Keywords
Direct oral anticoagulants - life-threatening bleeding - emergency operation - Antidotes
