The
PAUSE trial (Douketis 2019, see ref) demonstrated the favorable safety
and effectiveness of a standardized approach to stopping and then
resuming DOAC's around the time of surgery. To use this protocol, one
needs their list of high and low bleeding risk surgeries, and one needs
their management protocol table. Both are linked here.
Note
that the PAUSE trial was performed on roughly 3,000 atrial fibrillation
patients, not on patients with the other indication for DOAC's, VTE
prevention and treatment.
The PAUSE trial protocol used the following scheme to classify surgeries and procedures as high or low bleeding risk.
High Bleed Risk Surgery/Procedures 1) any surgery requiring neuraxial anesthesia - neuraxial anesthesia/injection - epidural anesthesia/injection 2) major intracranial or neuraxial surgery - brain cancer resection - laminectomy or neuraxial tumour resection - intracranial (subdural, epidural) bleed evacuation 3) major thoracic surgery - lobectomy, pneumonectomy - esophagectomy 4) major cardiac surgery - coronary artery bypass - valve replacement or repair 5) major vascular surgery - aortic aneurysm repair - aortobifemoral bypass, popliteal bypass - carotid endarterectomy 6) major abdominopelvic surgery - hepatobiliary cancer resection - pancreatic cancer or pseudocyst resection - colorectal and gastric cancer resection - diverticular disease resection - inflammatory bowel disease resection - renal cancer resection - bladder cancer resection - endometrial cancer resection - ovarian cancer resection - radical prostatectomy 7) major orthopedic surgery - hip arthroplasty or hip fracture repair - knee arthroplasty or tibial osteotomy - shoulder arthroplasty - metatarsal osteotomy 8) other major cancer or reconstructive surgery - head and neck cancer surgery - reconstructive facial, abdominal, limb surgery
Below
is the explanatory caption for DOAC mgmt table. The public webpage for
the table itself at JAMA oddly does not include the caption, so here it
is:
No DOAC was
taken on certain days (shaded) and on the day of the elective surgery or
procedure. The light blue arrows refer to an exception to the basic
management, a subgroup of patients taking dabigatran with a creatinine
clearance (CrCl) less than 50 ng/mL. The orange arrows refer to patients
having a high–bleed-risk surgical procedure. Dark blue arrows refer to
patients having a low–bleed-risk surgical procedure. The thickened
orange part of arrows refer to flexibility in the timing of DOAC
resumption after a procedure.
footnote a: Cancer diagnosed within 3 months or has been treated within 6 months or metastatic.