PB1068 - Management of patients requiring oral anticoagulant reversal for surgical emergencies or major bleeding: clinical practice in the United States

Tuesday, June 25, 2024

13:45 – 14:45 ICT

Room: Exhibition Hall

Presenting Author(s)

Jerrold H. Levy, MD

Professor of Anesthesiology, Critical Care, and Surgery (Cardiac)
Duke University Medical Center
Durham, North Carolina, United States

Co-Author(s)

Joseph R. Shaw, MD, MSc, FRCPC

Hematologist
The Ottawa Hospital
Ottawa, Ontario, Canada
CM

Cheryl L. Maier

Assistant Professor; Coag lab director
Emory University School of Medicine
Atlanta, Georgia, United States
Jean M. Connors, MD

Hematologist, Medical Director Hemostatic and Antithrombotic Stewardship Service
Brigham and Women's Hospital
Boston, Massachusetts, United States
KG

Kamrouz Ghadimi

Associate Prof.
Duke University Medical Centre, Durham, NC
Durham, North Carolina, United States
AS

Alex Spyropoulos

Professor
The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
New York, New York, United States
James Douketis

Professor of Medicine
McMaster University
Hamilton, Ontario, Canada
RS

Roman M. Sniecinski

Professor
Emory University School of Medicine
Atlanta, Georgia, United States

Background: Patients receiving vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) have increased bleeding risk during emergency surgery. Guidelines recommend prothrombin complex concentrates (PCCs) for emergent VKA-reversal and off-label use for DOAC reversal when specific antidotes are unavailable. Although the factor Xa inhibitors are the most frequently used DOACs, the specific reversal agent andexanet-alfa has not been studied in surgical patients.

Aims: Identify current practice and knowledge gaps to improve VKA and DOAC-treated patient management for emergency surgery.

Methods: A 22-question clinical practice survey on perioperative anticoagulant and bleeding management was emailed to American Society of Anesthesiology members bi-weekly from 6/7/2023-8/11/2023. Responses were collected using the Survey Monkey platform. Simple statistics were used to describe results.

Results: Responses were received from 1014 anesthesiologists. PCCs were the most selected treatment for VKA reversal for emergency surgery (43.7%) and bleeding (48.9%) of which 38.8% and 41.7% were 4F-PCCs, Recombinant FVIIa (rFVIIa) use was 1.7%, and 3.8%, and FFP 26.8% and 31.4%.(Figure 1) For DOAC-reversal, PCCs were the most selected reversal agent for emergency surgery (65.9%) and major bleeding (62.5%), including 4F-PCCs, 3F-PCCs, and activated PCCs (Figure 2). rFVIIa was used in 5.8% and 9.5%, and FFP was in 24-25% of respondents for bleeding or surgery. Of respondents answering DOAC reversal questions and the use of PCCs, 53.1% had unrestricted access, 8.7% used per institution protocol, 18.9% required approval, and 19.3% had no access.

Conclusion(s): 4F-PCC is the most commonly used reversal agent for major bleeding or emergency surgery in patients taking VKAs or DOACs, although FFP and rFVIIa continue to be used. Despite US off-label 4F-PCC use, more respondents reported PCCs as the primary treatment for DOAC-reversal or bleeding management. Studies investigating management strategies and associated clinical outcomes alongside guideline recommendations and provider education are needed to optimize perioperative management of VKA and DOAC-treated patients.