3.2 Specific targeted treatment:
Several recommendations can be made concerning the acute management of
coagulopathy in patients undergoing emergent surgical intervention and
are summarized in (table 2). Activated oral charcoal is given if DOAC
was last ingested within 2-4 hours. Non-specific prohemostatic agents
can be used including prothrombin complex concentrate (PCC), and
specific reversal agents (antidotes) are administered. Two specific DOAC
reversal agents have been approved by the US food and drug
administration (FDA): idarucizumab for reversal of dabigatran and
Andexanet alfa for reversal of apixaban and
rivaroxaban.29 The followings are worthwhile noting
with regards to specific anticoagulant at hand:
1- Vitamin K antagonists (VKA): Warfarin (Coumadin )
In a review by Goldstein et al, four-factor PCC (4F-PCC) was
superior to plasma for rapid INR reversal and effective hemostasis in
patients requiring VKA reversal for urgent surgical procedures (most
were non-cardiac).30 One study reported on 40 patients
on oral VKA, mainly for AF, who underwent urgent cardiac surgery and
were randomized to fresh frozen plasma (FFP) and PCC. Patients received,
pre CPB, either 2 units of FFP or half of the calculated PCC dose.
Post-bypass, they received 2 more units of FFP or the second half of PCC
dose. They noted that reversal with PCC was faster and bleeding was
less.31