Key result
Anesthetists favor longer 3- to 5-day pre-neuraxial DOAC interruptions than medical specialists.
Why the study?
The perioperative management of patients taking a DOAC who require high-bleed-risk surgery and/or neuraxial anesthesia is uncertain.
What are the current clinician practices regarding DOAC interruption intervals for patients undergoing high-bleed-risk surgery with neuraxial anesthesia?
Cross-Sectional (n=399)
What are the current clinician practices regarding DOAC interruption intervals for patients undergoing high-bleed-risk surgery with neuraxial anesthesia?
There is significant practice variability between anesthetists and medical specialists regarding DOAC interruption before neuraxial anesthesia, highlighting the need for a randomized trial.
Divergent specialty preferences reveal marked practice variability; leaves open optimal DOAC interruption before neuraxial anesthesia and supports RCT evaluation.
BACKGROUND: The perioperative management of patients taking a direct oral anticoagulant (DOAC) who require a high-bleed-risk surgery and/or neuraxial anesthesia is uncertain. We surveyed clinician practices relating to DOAC interruption and related perioperative management in patients having high-bleed-risk surgery with neuraxial anesthesia, and assess the suitability of a randomized trial of different perioperative DOAC management strategies. METHODS: We surveyed members of the American Society of Regional Anesthesia and Pain Medicine, the Canadian Anesthesia Society and Thrombosis Canada. We developed four clinical scenarios involving DOAC-treated patients who required anticoagulant interruption for elective high-bleed-risk surgery. In three scenarios, patients were to receive neuraxial anesthesia, and in one scenario they were to receive general anesthesia. We also asked about the merit of a randomized trial to compare a 2-day versus longer (3- to 5-day) duration of DOAC interruption. RESULTS: There were 399 survey respondents of whom 356 (89%) were anesthetists and 43 (11%) were medical specialists. The responses indicate uncertainty about the DOAC interruption interval for high-bleed-risk surgery and/or neuraxial anesthesia; anesthetists favor 3- to 5-day interruption whereas medical specialists favor 2-day interruption. Anesthetists were unwilling to proceed with neuraxial anesthesia in patients with a 2-day DOAC interruption interval, preferring to cancel the surgery or switch to general anesthesia. There is general agreement on the need for a randomized trial in this field to compare a 2-day and a 3- to 5-day DOAC interruption management strategy. CONCLUSIONS: There is variability in practices relating to the perioperative management of DOAC-treated patients who require a high-bleed-risk surgery with neuraxial anesthesia; this variability relates to the duration of DOAC interruption in such patients.
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Douketis et al. (2020) conducted a cross-sectional in Perioperative DOAC management (n=399). Survey of clinical scenarios was evaluated on Recommended DOAC interruption interval. Anesthetists favored a 3- to 5-day DOAC interruption interval before neuraxial anesthesia, whereas medical specialists favored a 2-day interruption.
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