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Management of the Trauma Patient on Direct Oral
Anticoagulants. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0253-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Raval AN, Cigarroa JE, Chung MK, Diaz-Sandoval LJ, Diercks D, Piccini JP, Jung HS, Washam JB, Welch BG, Zazulia AR, Collins SP. Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e604-e633. [PMID: 28167634 DOI: 10.1161/cir.0000000000000477] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Non-vitamin K oral anticoagulants (NOACs) are now widely used as alternatives to warfarin for stroke prevention in atrial fibrillation and management of venous thromboembolism. In clinical practice, there is still widespread uncertainty on how to manage patients on NOACs who bleed or who are at risk for bleeding. Clinical trial data related to NOAC reversal for bleeding and perioperative management are sparse, and recommendations are largely derived from expert opinion. Knowledge of time of last ingestion of the NOAC and renal function is critical to managing these patients given that laboratory measurement is challenging because of the lack of commercially available assays in the United States. Idarucizumab is available as an antidote to rapidly reverse the effects of dabigatran. At present, there is no specific antidote available in the United States for the oral factor Xa inhibitors. Prothrombin concentrate may be considered in life-threatening bleeding. Healthcare institutions should adopt a NOAC reversal and perioperative management protocol developed with multidisciplinary input.
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Feeney JM, Neulander M, DiFiori M, Kis L, Shapiro DS, Jayaraman V, Marshall WT, Montgomery SC. Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma. Injury 2017; 48:47-50. [PMID: 27582383 DOI: 10.1016/j.injury.2016.08.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/25/2016] [Accepted: 08/26/2016] [Indexed: 02/02/2023]
Abstract
METHODS We queried our Trauma Quality Improvement Program registry for patients who presented between 6/1/2011 and 9/1/2015 with severe (injury severity score (ISS)>15) blunt traumatic injury during anticoagulant use. Patients were then grouped into those prescribed warfarin and patients prescribed any of the available novel Direct Oral Anticoagulants (DOAC) medications. We excluded severe (AIS≧4) head injuries. RESULTS There were no differences between DOAC and warfarin groups in terms of age, gender mean ISS, median hospital or intensive care unit lengths of stay, complication proportions, numbers of complications per patient, or the proportion of patients requiring transfusion. Finally, excluding patients who died, the observed proportion of discharge to skilled nursing facility was similar. In our sample of trauma patients, DOAC use was associated with significantly lower mortality (DOAC group 8.3% vs. warfarin group 29.5%, p<0.015). The ratio of units transfused per patient was also lower in the DOAC group (2.8±1.8 units/patient in the DOAC group vs. 6.7±6.4 units per patient in the warfarin group; p=0.001). CONCLUSION In conclusion, we report an association with decrease in mortality and a decrease in transfused blood products in severely injured trauma patients with likely minimal or no head injury taking novel DOACs over those anticoagulated with warfarin for outpatient anticoagulation.
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Affiliation(s)
- James M Feeney
- Saint Francis Hospital and Medical Center, Department of Surgery, 114 Woodland St. Hartford, CT 06103, USA; University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT 06030, USA.
| | - Matthew Neulander
- Saint Francis Hospital and Medical Center, Department of Emergency Medicine, 114 Woodland St. Hartford, CT 06103, USA; University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT 06030, USA
| | - Monica DiFiori
- Trinity College, 300 Summit Street, Hartford, CT 06106, USA
| | - Lilla Kis
- Trinity College, 300 Summit Street, Hartford, CT 06106, USA
| | - David S Shapiro
- Saint Francis Hospital and Medical Center, Department of Surgery, 114 Woodland St. Hartford, CT 06103, USA; University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT 06030, USA
| | - Vijay Jayaraman
- Saint Francis Hospital and Medical Center, Department of Surgery, 114 Woodland St. Hartford, CT 06103, USA; University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT 06030, USA
| | - William T Marshall
- Saint Francis Hospital and Medical Center, Department of Surgery, 114 Woodland St. Hartford, CT 06103, USA; University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT 06030, USA
| | - Stephanie C Montgomery
- Saint Francis Hospital and Medical Center, Department of Surgery, 114 Woodland St. Hartford, CT 06103, USA; University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT 06030, USA
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Sarma A, Rossi JE, Connors JM, Giugliano RP. Dabigatran excess: case report and review of the literature. Cardiol Ther 2013; 2:111-24. [PMID: 25135294 PMCID: PMC4107435 DOI: 10.1007/s40119-013-0016-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Novel oral anticoagulants are increasingly used for stroke prophylaxis in patients with non-valvular atrial fibrillation. While these agents offer a more predictable pharmacokinetic profile, the lack of readily available laboratory tests to monitor the level of anticoagulation and absence of an antidote or established therapies to reverse the anticoagulant effect make management of cases of over-anticoagulation challenging. CASE REPORT In this case report an 87-year-old man with a history of atrial fibrillation presented with dabigatran excess in the setting of life-threatening, acute renal and hepatic failure. The authors review the use of dabigatran in elderly patients, the available data on management of patients with excess anticoagulation, and the potential options for reversal of the anticoagulation effect. CONCLUSION Further investigation into reliable means of monitoring and reversing the anticoagulant effect of dabigatran is crucial to the management of such patients.
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Affiliation(s)
- Amy Sarma
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Jeffrey E. Rossi
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Jean M. Connors
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Hematology Division, Brigham and Women’s Hospital, Boston, MA USA
| | - Robert P. Giugliano
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA USA
- TIMI Study Office, 350 Longwood Avenue, 1st Floor Offices, Boston, MA 02115 USA
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Nardi G, Agostini V, Rondinelli BM, Bocci G, Bartolomeo SD, Bini G, Chiara O, Cingolani E, Blasio ED, Gordini G, Coniglio C, Pellegrin C, Targa L, Volpi A. Prevention and treatment of trauma induced coagulopathy (TIC). An intended protocol from the Italian trauma update research group. ACTA ACUST UNITED AC 2013. [DOI: 10.7243/2049-9752-2-22] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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