In part 3 of this 4-part series. Dr. Baugh discusses the role of pre-procedural anticoagulation reversal.
Faculty: Christopher Baugh, MD, MBA
Vice Chair of Clinical Affairs Department of Emergency Medicine | Brigham and Women's Hospital Associate Professor | Harvard Medical School
Dr. Baugh has published on the clinical and administrative aspects of observation care in the New England Journal of Medicine, Health Affairs, Annals of Emergency Medicine, and Academic Emergency Medicine. He previously served as Chair of the Observation Medicine Section of the American College of Emergency Physicians.
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- Let's discuss giving a reversal agent to a patient who is not currently bleeding. There are times when a patient taking an anticoagulant has an indication for an emergent invasive procedure with elevated bleeding risk, including common ED procedures, such as lumbar puncture or thoracentesis. In addition, some patients may need to go to a procedural area such as the OR for an even more invasive procedure, such as an emergency surgery for ischemic bowel requiring a laparotomy. For all of these procedures, there are multiple variables to consider. First, what is the indication for anticoagulation? There is a spectrum of risk among all possible indications, such as embolic stroke prevention in atrial fibrillation versus mechanical heart valves. You should think about the underlying risk of thrombosis for the patient in front of you and how that risk relates to the bleeding risk of their procedure. Second, which anticoagulant is onboard? When was the last dose taken? Half-life? And can you quickly and accurately measure anticoagulant activity? What is the risk-benefit and duration of action of reversal and replacement options? And are there FDA indications for these options? And does your local institutional policy allow you to give them in a pre-procedural setting? Lastly, consider the urgency of the procedure and the risk-benefit of empiric treatment versus other alternatives. You should also think about the risks of delaying the procedure and simply holding the anticoagulant, which will typically mean admitting the patient and deferring the procedure to the inpatient team or interventional specialists. These are complex decisions that should be made collaboratively with consultants and, if capable, the patient and their caregivers. You wanna time up, keep reversal, with when the bleeding risk will be highest. And document your decision-making process, regardless of if you decide to reverse or not. Notably, 4-factor prothrombin complex concentrate and andexanet alpha are not currently FDA approved for non-bleeding preoperative use.
