Clinical Course and Management of Patients with Emergency Surgery Treated with Direct Oral Anticoagulants or Vitamin K Antagonists—Results of the German Prospective RADOA-Registry
Abstract
:1. Introduction
2. Materials and Methods
2.1. Patients
- Age > 18 years.
- Patients anticoagulated with a DOAC or phenprocoumon needing an urgent surgical intervention (not caused by severe bleeding) within 24 h after admission.
2.2. Study Design and Oversight
2.3. Definition of INR-Rebound
2.4. Definition of Major Bleeding
- good hemostasis (for the type of surgery performed)
- severe bleeding outside the surgical area with a drop in hemoglobin ≥ 2 g/dL or a need of >2 RBC transfusions within 24 h after admission
- bleeding in the surgical area requiring re-surgery
- bleeding in the surgical area that was unexpected and persistent and/or led to hemodynamic instability (drop in Hb value ≥ 2 g/dL or transfusion of >2 RBC) within 24 h after admission
2.5. Ethics
2.6. Statistics
3. Results
3.1. Demographic Data of Included Patients
3.2. Management
Use of Specific Antidotes
3.3. Bleeding Complications
3.4. INR-Rebound
3.5. Thromboembolic Complications
3.6. In-Hospital Mortality (until Day 30 after Admission)
4. Discussion
Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Total (n = 78) | DOAC 4 (n = 44) | VKA (n = 34) | p-Values 1 | |
---|---|---|---|---|
Demographic data | ||||
Female sex | 31 (40%) | 23 (52%) | 8 (26%) | 0.012 |
Age (years) | 76.5 (43–94) | 75.5 (43–94) | 76.5 (46–91) | >0.20 |
Acute renal failure | 5 (6%) | 2 (5%) | 3 (9%) | >0.20 |
Surgery type | ||||
traumatic | 31 (40%) | 24 (55%) | 7 (21%) | 0.003 |
fractures | 27 (35%) | 20 (46%) | 7 (21%) | 0.031 |
acute abdomen | 23 (30%) | 12 (27%) | 11 (32%) | >0.20 |
GI tract | 18 (23%) | 9 (21%) | 9 (27%) | >0.20 |
CNS | 3 (4%) | 2 (5%) | 1 (3%) | >0.20 |
abscess | 1 (1%) | 1 (2%) | 0 (0.0%) | -- |
Open-heart surgery | 11 (14%) | 4 (9%) | 7 (21%) | 0.195 |
vascular | 7 (9%) | 2 (5%) | 5 (15%) | >0.20 |
other | 6 (8%) | 3 (7%) | 3 (9%) | >0.20 |
Co-medication, indication for anticoagulation and bleeding risk | ||||
Antiplatelet drugs | 11 (14%) | 6 (14%) | 5 (15%) | >0.20 |
Anti-inflammatory drugs | 4 (5%) | 1 (2%) | 3 (9%) | >0.20 |
Indication | 0.155 | |||
atrial fibrillation | 58 (74%) | 34 (77%) | 24 (71%) | |
venous thrombosis | 5 (6%) | 4 (9%) | 1 (3%) | |
postoperative prophylaxis | 4 (5%) | 1 (2%) | 3 (9%) | |
arterial thrombosis | 4 (5%) | 1 (2%) | 3 (9%) | |
artificial heart valve | 2 (3%) | 0 (0%) | 2 (6%) | |
other | 5 (6%) | 4 (9%) | 1 (3%) | |
CHADS-VASC Score | 5.0 (1.0–9.0) | 5.0 (2.0–9.0) | 5.0 (1.0–8.0) | >0.20 |
HASBLED Score 2 | 3.0 (0.0–5.0) | 2.0 (0.0–4.0) | 3.0 (0.0–5.0) | 0.126 |
HASBLED Score modified 3 | 2.0 (0.0–5.0) | 2.0 (0.0–4.0) | 3.0 (0.0–5.0) | >0.20 |
Delay of Emergency Surgery in Hours | DOAC (n = 44) | VKA (n = 34) |
---|---|---|
No delay | 35 (80%) | 27 (79%) |
4–6 h | 4 (9%) | 4 (12%) |
7–12 h | 2 (5%) | 1 (3%) |
13–24 h | 3 (7%) | 2 (6%) |
Patient/ Anticoagulant | Age | Gender | INR/DOAC Level | Type of Surgery | Preoperative Treatment | Bleeding ≤24 h after Admission | Postoperative Hemostatic Treatment ≤24 h after Admission | INR-Rebound | Repeat Surgery | Bleeding > 24 h after Admission | Postoperative Hemostatic Treatment > 24 h after Admission | In-Hospital Death |
---|---|---|---|---|---|---|---|---|---|---|---|---|
VKA1 | 66 | m | 3.9 | acute abdomen | PCC | yes | PCC, RBC, Vit K | yes | yes | no | - | no |
VKA2 | 64 | m | 2.8 | open heart surgery | TA | yes | PCC, FFP, TA, P, RBC, PC | no | no | no | - | no |
VKA3 | 82 | m | 2.2 | open heart surgery | no | yes | PCC, FFP, TA, P, RBC, PC | yes | no | no | - | yes, day 22 # |
VKA4 | 53 | m | 1.4 | open heart surgery | no | yes | PCC, FFP, TA, P, RBC, PC, F | no | no | no | - | no |
VKA5 | 66 | m | 2.0 | gluteal fasciitis | no | no | PCC | yes | yes | yes, day 3 | PCC, FFP, TA, RBC, F, PCC, Vit K, aFVII, FXIII | yes, day 14 # |
VKA6 | 81 | m | 3.1 | subdural hematoma | PCC, TA | yes | PCC, RBC, Vit K | yes | yes | yes, day 2 | PCC | yes, day 2 ## |
VKA7 | 69 | m | 1.8 | peripheral artery occlusion | PCC, Vit K | no | TA, P | yes | yes | yes, day 8 | FFP, RBC, Vit K | no |
DOAC 1 * | 89 | f | 279 ng/mL | acute abdomen | PCC | yes | PCC, Vit k, TA | - | yes | yes, day 2 | PCC | no |
DOAC 2 ** | 74 | m | 333 ng/mL | open heart surgery | no | yes | - | - | yes | yes, day 1–3 | PCC, FFP, RBC, PC, F, aFVII | no |
DOAC 3 *** | 72 | m | 62 ng/mL | open heart surgery | no | yes | PCC, Vit k, TA, P | - | no | yes, day 3–4 | PCC, RBC, PC, F, Vit K | yes, day 7 # |
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Last, J.; Herrmann, E.; Birschmann, I.; Lindau, S.; Konstantinides, S.; Grottke, O.; Nowak-Göttl, U.; Zydek, B.; von Heymann, C.; Sümnig, A.; et al. Clinical Course and Management of Patients with Emergency Surgery Treated with Direct Oral Anticoagulants or Vitamin K Antagonists—Results of the German Prospective RADOA-Registry. J. Clin. Med. 2024, 13, 272. https://doi.org/10.3390/jcm13010272
Last J, Herrmann E, Birschmann I, Lindau S, Konstantinides S, Grottke O, Nowak-Göttl U, Zydek B, von Heymann C, Sümnig A, et al. Clinical Course and Management of Patients with Emergency Surgery Treated with Direct Oral Anticoagulants or Vitamin K Antagonists—Results of the German Prospective RADOA-Registry. Journal of Clinical Medicine. 2024; 13(1):272. https://doi.org/10.3390/jcm13010272
Chicago/Turabian StyleLast, Jana, Eva Herrmann, Ingvild Birschmann, Simone Lindau, Stavros Konstantinides, Oliver Grottke, Ulrike Nowak-Göttl, Barbara Zydek, Christian von Heymann, Ariane Sümnig, and et al. 2024. "Clinical Course and Management of Patients with Emergency Surgery Treated with Direct Oral Anticoagulants or Vitamin K Antagonists—Results of the German Prospective RADOA-Registry" Journal of Clinical Medicine 13, no. 1: 272. https://doi.org/10.3390/jcm13010272