Perioperative management of anticoagulation]

The aim of the perioperative management of anticoagulation in patients with long-term oral anticoagulation is to minimize bleeding complications of surgical interventions. We aimed to give a summary of current data and to give practical recommendations for colleagues practicing surgery. This article gives a narrative overview of available data from 31 publications between 2000 and 2013. Every perioperative decision on whether to continue oral anticoagulation is preceded by an assessment of the risk of bleeding and embolism. In cases with a low risk of bleeding, oral anticoagulation can usually be continued. In contrast, for larger interventions with a moderate to high risk of bleeding, a discontinuation of phenprocoumon with temporary bridging is required. In this case it is common practice to discontinue phenprocoumon 7-9 days preoperatively and administer heparin mostly in the form of low molecular weight heparin (LMWH) depending on the international normalized ratio (INR). In contrast perioperative management of direct oral anticoagulants (DOAC) is discussed controversially. Based on the pharmacokinetics of the DAOC, the recommendations are to minimize the anticoagulation-free interval to 2-4 half-lives (HWZ) preoperatively (1-5 days) and early postoperative restart. In this case no bridging is necessary. On the other hand, an early interruption of DOAC 5 days prior to surgery to a minimum of 2 days postoperatively is favored by some surgeons to assure an adequate perioperative hemostasis. Depending on the risk of thromboembolism, bridging is required. These recommendations are justified by limited clinical experience and the absence of antagonism. The perioperative management of coagulation is still a challenge. While there are consolidated decision aids for phenprocoumon, the approach under DOAC treatment is still controversial due to limited data.