New and old oral anticoagulants in anesthesia practice: a balancing approach

ABSTRACT

For decades, vitamin K antagonist warfarin has been used for thromboprophylaxis or stroke prevention in atrial fibrillation. Recently, direct thrombin inhibitor - dabigatran and factor Xa inhibitors - rivaroxaban and apixaban, have emerged as alternatives to warfarin. The perioperative management of antithrombotic therapy involves establishing a balance between hemorrhagic risk and thrombotic risk. Routine coagulation assays like prothrombin time and activated partial thromboplastin time provide a crude estimation of their activity. Further, no specific antidotes are available to reverse their effect. These drugs are discontinued before elective surgery and timing is based on the patient's renal status also. For emergency surgery or bleeding, the management includes the principles of bleeding control; hemodialysis may be effective for dabigatran. Prothrombin complex concentrates are found to be more effective than frozen plasma but more studies are warranted