Perioperative Management of the Direct Oral Anticoagulants: A Case-Based Review.

The periprocedural management of patients on direct oral anticoagulants (DOACs) is a common but potentially challenging clinical problem because there are few prospective studies to guide clinical decisions. Retrospective analyses from randomized trials and observational data suggest that DOACs can be managed in a standardized manner, based on surgical and patient characteristics, that does not result in excess major bleeding or thrombosis. In a case-based manner, this article presents a perioperative DOAC management algorithm and reviews the available and emerging evidence supporting the safety and efficacy of this approach. A free online clinical guidance tool is available from Thrombosis Canada that includes the proposed management algorithm.

Prevention of venous thromboembolism in the Enhanced Recovery After Surgery (ERAS) setting: an evidence-based review.

PURPOSE: To review the evidence surrounding appropriate prophylaxis for venous thromboembolism (VTE) in patients undergoing surgery. PRINCIPAL FINDINGS: Appropriate prophylactic strategies for surgical patients have been defined in major society guidelines. We review the evidence behind these guidelines in a case-based format, including patients with a high risk of bleeding, history of heparin-induced thrombocytopenia, obesity, and cancer. Selecting the most suitable means for VTE prophylaxis includes evaluating patient, anesthetic, and surgical factors. Nevertheless, pharmacologic VTE prophylaxis will be appropriate for the vast majority of inpatients undergoing surgery. CONCLUSIONS: Venous thromboembolism is a serious but preventable complication of hospitalization, especially among surgical patients. Historically, it has accounted for a high burden of postoperative morbidity and mortality. In the Enhanced Recovery After Surgery era, our aim should be no less ambitious than the eradication of postoperative VTE.