What to Do When an Anticoagulated Patient Needs Surgery

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The MD Magazine Peer Exchange “Novel Anticoagulation Options: Target-Specific Oral Agents and Their Antidotes” features leading physician specialists discussing key topics in anticoagulation therapy, including the clinical characteristics of current and emerging agents and criteria for use in specific patient populations.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

• Scott Kaatz, DO, MSc, Chief Quality Officer at Hurley Medical Center in Flint, Michigan, and clinical associate professor at Michigan State University
• Seth Bilazarian, MD, clinical and interventional cardiologist at Pentucket Medical and instructor of medicine at Harvard Medical School
• Gerald Naccarelli, MD, Bernard Trabin Chair in Cardiology, professor of medicine and chief of the Division of Cardiology at Penn State University School of Medicine, and associate clinical director at Penn State Heart and Vascular Institute in Hershey, Pennsylvania
• Christian T. Ruff, MD, associate physician in the cardiovascular medicine division at Brigham and Women’s Hospital, and assistant professor of medicine at Harvard Medical School in Boston

When surgery is needed, it seems that we are moving toward continuing anticoagulation and learning how to better manage the hemorrhage, according to the panel. Emergency physicians are very good at managing bleeding in general. Also, electronic medical records can provide tools, and Ruff said that a lot of the panic can be managed simply by talking to the patient, asking when he/she took the last dose of anticoagulant therapy.

Kaatz said he is against monitoring blood tests like Xa level and thrombin time and clotting time. The only exception to this would be urgent surgeries. In these situations, if the time of the patient’s last dose is unknown, measuring prothrombin for the Xa inhibitors can be very helpful.

When a patient has life-threatening bleeding and time is of the essence, prothrombin complex concentrates are available in every hospital, and they are pretty effective in reversing at least the laboratory abnormality, said Ruff.