Universität zu Köln

Maegele, Marc, Grottke, Oliver ORCID: 0000-0002-0722-3122, Schoechl, Herbert, Sakowitz, Oliver, Spannagl, Michael and Koscielny, Juergen (2016). Direct Oral Anticoagulants in Emergency Trauma Admissions Perioperative Management, and Handling Hemorrhage. Dtsch. Arztebl. Int., 113 (35-36). S. 575 - 585. COLOGNE: DEUTSCHER AERZTE-VERLAG GMBH. ISSN 1866-0452

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Abstract

Background: Direct (non-vitamin-K-dependent) oral anticoagulants (DOAC) are given as an alternative to vitamin K antagonists (VKA) to prevent stroke and embolic disease in patients with atrial fibrillation that is not due to pathology of the heart valves. Fatal hemorrhage is rarer when DOACs are given (non-valvular atrial fibrillation: odds ratio [OR] 0.68; 95% confidence interval [95% CI: 0.48; 0.96], and venous thromboembolism: OR 0.54; [0.22; 1.32]). 48% of emergency trauma patients need an emergency operation or early surgery. Clotting disturbances elevate the mortality of such patients to 43%, compared to 17% in patients without a clotting disturbance. This underscores the impor tance of the proper, targeted treatment of trauma patients who are taking DOAC. Methods: This review is based on articles retrieved by a selective search in PubMed and on a summary of expert opinion and the recommendations of the relevant medical specialty societies. Results: Peak DOAC levels are reached 2-4 hours after the drug is taken. In patients with normal renal and hepatic function, no drug accumulation, and no drug interactions, the plasma level of DOAC 24 hours after administration is generally too low to cause any clinically relevant risk of bleeding. The risk of drug accumulation is higher in patients with renal dysfunction (creatinine clearance [CrCl] of 30 mL/min or less). Dabigatran levels can be estimated from the thrombin time, ecarin clotting time, and diluted thrombin time, while levels of factor Xa inhibitors can be estimated by means of calibrated chromogenic anti-factor Xa activity tests. Routine clotting studies do not reliably reflect the anticoagulant activity of DOAC. Surgery should be postponed, if possible, until at least 24-48 hours after the last dose of DOAC. For patients with mild, non-life threatening hemorrhage, it suffices to discontinue DOAC; for patients with severe hemorrhage, there are special treatment algorithms that should be followed. Conclusion: DOACs in the setting of hemorrhage are a clinical challenge in the traumatological emergency room because of the inadequate validity of the relevant laboratory tests. An emergency antidote is now available only for dabigatran.

Item Type:	Journal Article
Creators:	Creators Email ORCID ORCID Put Code Maegele, Marc UNSPECIFIED UNSPECIFIED UNSPECIFIED Grottke, Oliver UNSPECIFIED orcid.org/0000-0002-0722-3122 UNSPECIFIED Schoechl, Herbert UNSPECIFIED UNSPECIFIED UNSPECIFIED Sakowitz, Oliver UNSPECIFIED UNSPECIFIED UNSPECIFIED Spannagl, Michael UNSPECIFIED UNSPECIFIED UNSPECIFIED Koscielny, Juergen UNSPECIFIED UNSPECIFIED UNSPECIFIED
URN:	urn:nbn:de:hbz:38-262626
DOI:	10.3238/arztebl.2016.0575
Journal or Publication Title:	Dtsch. Arztebl. Int.
Volume:	113
Number:	35-36
Page Range:	S. 575 - 585
Date:	2016
Publisher:	DEUTSCHER AERZTE-VERLAG GMBH
Place of Publication:	COLOGNE
ISSN:	1866-0452
Language:	English
Faculty:	Unspecified
Divisions:	Unspecified
Subjects:	no entry
Uncontrolled Keywords:	Keywords Language PROTHROMBIN COMPLEX CONCENTRATE; DIRECT THROMBIN INHIBITOR; ATRIAL-FIBRILLATION; FACTOR-XA; INTRACRANIAL HEMORRHAGE; VENOUS THROMBOEMBOLISM; BLEEDING COMPLICATIONS; DABIGATRAN ETEXILATE; REVERSAL STRATEGIES; EX-VIVO Multiple languages Medicine, General & Internal Multiple languages
Refereed:	Yes
URI:	http://kups.ub.uni-koeln.de/id/eprint/26262