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    Oral Communication

    Coagulation and Natural Anticoagulants

    DOAC Reversal: Current Practice and Emerging Concepts

    OC 31.1 - Management and Outcomes of Anticoagulated Patients in Urgent Surgery: The PAUSE-ER Study

    Monday, June 26, 2023
    10:45 – 11:00 ET
    Room: 516
    Session Available As: Live-Stream and On-Demand
    Background: Few data describe the perioperative management and outcomes of patients receiving oral anticoagulant (OAC) therapy who require urgent (unplanned) surgery. While limited available evidence suggests high rates of thromboembolism, bleeding and death in this setting, substantial knowledge gaps remain.

    Aims: We aimed to (i) determine the incidence of adverse events (thrombosis, bleeding, death) among OAC-treated patients requiring urgent surgery, (ii) examine management and resource utilization, and (iii) explore factors associated with adverse outcomes.

    Methods: PAUSE-ER was a prospective observational study conducted at 10 sites (Canada, US, Greece, Argentina). OAC-treated adults requiring OAC interruption for urgent (unplanned) surgery/invasive procedure (within 72 hours) were eligible. Patients undergoing elective (planned), or minimal bleed risk surgeries/procedures not requiring OAC interruption were excluded. Data were collected from medical records and telephone follow-up at 30 days.

    Results: 242 participants were enrolled (2019-2022). The mean age was 75 years and 50% were female. OAC use comprised apixaban (40%), warfarin (38%), rivaroxaban (16%), edoxaban (1%) and dabigatran (0.4%). The commonest indication for OAC was atrial fibrillation (74%). The most common surgeries were orthopedic (n=84), general surgery (n=42), vascular surgery (n=16), neurosurgery (n=16), interventional radiology procedures (n=10), urologic surgery (n=9), and cardiothoracic surgery (n=8). Most patients (76%) received general anesthesia and 5% had neuraxial anesthesia. Perioperatively, patients received idarucizumab (n=1), andexanet-alfa (n=1), prothrombin complex concentrate (n=45), plasma (n=8), vitamin K (n=61) and tranexamic acid (n=31). At 30-days follow-up, 12 patients (5%) died, 18 (7%) had bleeding complications and 4 (2%) experienced thromboembolic events (ischemic stroke [n=3] and pulmonary embolism [n=1]).

    Conclusion(s): In the first prospective evaluation of unselected OAC-treated patients requiring urgent surgery, we showed that management was variable and adverse outcome rates appeared higher than those observed after elective (planned) surgery. Further research aims to inform best practices for OAC management to reduce morbidity and mortality.

    Learning Objectives:

    • Describe the limited existing data and high risk of adverse outcomes after urgent (unplanned) surgery among patients receiving oral anticogulants
    • Discuss the results of a prospective international cohort study of patients receiving oral anticoagulants who undergo urgent (unplanned) surgery including management and outcomes (bleeding, thrombosis, death)
    • Discuss the need for future research to determine the optimal management of patients receiving oral anticoagulants who require urgent (unplanned) surgery