Reversing the Effect of Anticoagulants Safety in Patients Undergoing Emergency Surgery

Anticoagulants are widely used, especially in the elderly, for the prevention and treatment of thromboembolic complications and in high-risk post myocardial infarction. Above all, Vitamin K antagonists (VKAs) are predominantly prescribed in the general population. Unfortunately, due to VKAs intrinsic pharmacodynamic and pharmacokinetic properties (high interindividual variability, food interaction, narrow therapeutic window), routine management of VKAs can be challenging both for the patients and for the clinicians, consequently, the number of patients taking non-vitamin K oral anticoagulants (i.e., direct oral anticoagulants) is increased in the last years. In fact, direct oral anticoagulants (DOACs) have progressively been used owing to their shorter half-lives, rapid onset, and predictable pharmacodynamics. In the elderly, the incidence of pharmacologically induced coagulopathy, in trauma or emergency invasive procedure, is responsible for a huge increase of bleeding complications that can be life-threatening. Consequently, the perioperative management of patients taking anticoagulant agents and undergoing surgery is particularly challenging. A precise balance has to be reached between the risk of bleeding and the risk of thromboembolism. Then, when a decision of stopping anticoagulant has been made, it is vital to determine the time of anticoagulation interruption, resumption, and the necessity of bridging. Furthermore, in emergency scenario, the reversal of the anticoagulant should be mandatory, not only to prevent but also to treat perioperative bleeding. In this situation, a specific reversal strategy has to be chosen on the basis of the type of anticoagulants. In this chapter, we aimed to provide an overview of the current knowledge regarding the perioperative management of patients receiving anticoagulants and undergoing surgery.