What is the clinical evidence from this study?

Study design: Editorial. Population: Perioperative anticoagulation management. Intervention: Multidisciplinary harmonization of anticoagulation pauses.

What question did this study set out to answer?

To highlight inconsistencies in anticoagulation management across specialties and propose strategies for harmonization.

April 28, 2026Open Access

Anticoagulation Pauses and Anesthetic Options: A Case for Multidisciplinary Harmonization

Key Result

Multidisciplinary, institution-specific frameworks are needed to harmonize conflicting perioperative anticoagulation interruption guidelines to safely preserve regional anesthesia options.

Key Points

To highlight inconsistencies in anticoagulation management across specialties and propose strategies for harmonization.
Review of existing anticoagulation guidelines from multiple medical specialties.
Discussion of the variability in regional anesthesia protocols related to anticoagulant therapy.
Proposal of institution-specific frameworks for coordinated decision-making.
Inconsistent guidelines lead to varying practices in managing anticoagulation during perioperative care.
Emerging evidence shows that direct oral anticoagulant activity can persist even after guideline-recommended pauses.
There is a critical need for tailored strategies that consider pharmacokinetic variability across patient populations.

Structured PICO

Population

Perioperative patients on antithrombotic therapy

Institution-specific, multidisciplinary harmonization of perioperative anticoagulation guidelines is necessary to balance surgical bleeding risks with the safety requirements of regional anesthesia.

Limitations

Fixed pause intervals do not eliminate physiologic variability such as renal impairment, frailty, and polypharmacy.
Observational data suggest some patients retain measurable DOAC levels despite guideline-consistent interruption.

Abstract

Perioperative anticoagulation management is increasingly guided by recommendations from multiple specialties, including cardiology, thrombosis medicine, stroke medicine, and surgery. These frameworks, while intending to improve standardization of interruption and resumption strategies for antithrombotic therapy, are largely centered on surgical bleeding risk and thromboembolic risk, while regional anesthesia (RA) guidelines differ in pause intervals for many oral anticoagulants due to the differing thresholds for acceptable residual anticoagulant activity, with the potentially catastrophic consequences of neuraxial hematoma in mind. Emerging evidence also suggests that measurable direct oral anticoagulant (DOAC) activity may persist despite guideline-consistent interruption in some patients, highlighting pharmacokinetic variability in real-world perioperative populations. Multidisciplinary, institution-specific frameworks and testing of anticoagulant activity in select cases may help harmonize multiple sources of guidance and support coordinated decision-making across surgical, anesthesia, and perioperative care teams. In this perspective piece, we intend to highlight discrepancies in perioperative anticoagulation guidance and discuss ways to promote harmonization strategies with considerations for RA choices.

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