Perioperative management of patients taking direct oral anticoagulants: challenges in high-bleed-risk surgery and neuraxial anesthesia

Perioperative direct oral anticoagulants (DOACs) management has been supported by guidelines, however there is still limited high quality data to inform best practices regarding the perioperative management of DOAC-treated patients who need a high-bleed-risk surgery, including those receiving any neuraxial anesthesia. Currently there are two potential competing strategies known as the “PAUSE management” and “ASRA management”. PAUSE management, based on the Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE) study of patients with atrial fibrillation who underwent an elective surgery/procedure, provides a standardized 2 full-day DOAC interruption for high-bleed-risk surgery/procedure, without the need for pre-operative heparin bridging or DOAC level testing. ASRA management, based on recommendations from the American Society of Regional Anesthesia (ASRA) guidelines, is somewhat more complex to ensure no residual DOAC level at the time of a high-bleed-risk procedure, using longer DOAC interruption intervals. Despite convincing rationales of both approaches there is uncertainty as to whether to follow PAUSE- or ASRA-based perioperative DOAC management. The rationale of the PAUSE-2 trial is discussed. Optimal perioperative DOAC management should address the following questions, and will be discussed in this review: i) should DOAC be interrupted; ii) for how long should DOAC be interrupted; iii) is bridging with heparin necessary; iv) is DOAC level measurement necessary; and v) how to manage DOAC resumption? This approach will be illustrated with the following case: an 85-year-old female with colon cancer, atrial fibrillation, chronic heart failure, hypertension, diabetes mellitus, transient ischemic attack (CHADS2=6) and chronic kidney disease, treated with apixaban 5 mg twice-daily is scheduled to undergo open colectomy with neuraxial anesthesia