3.2 Specific targeted treatment:
Several recommendations can be made concerning the acute management of coagulopathy in patients undergoing emergent surgical intervention and are summarized in (table 2). Activated oral charcoal is given if DOAC was last ingested within 2-4 hours. Non-specific prohemostatic agents can be used including prothrombin complex concentrate (PCC), and specific reversal agents (antidotes) are administered. Two specific DOAC reversal agents have been approved by the US food and drug administration (FDA): idarucizumab for reversal of dabigatran and Andexanet alfa for reversal of apixaban and rivaroxaban.29 The followings are worthwhile noting with regards to specific anticoagulant at hand:
1- Vitamin K antagonists (VKA): Warfarin (Coumadin )
In a review by Goldstein et al, four-factor PCC (4F-PCC) was superior to plasma for rapid INR reversal and effective hemostasis in patients requiring VKA reversal for urgent surgical procedures (most were non-cardiac).30 One study reported on 40 patients on oral VKA, mainly for AF, who underwent urgent cardiac surgery and were randomized to fresh frozen plasma (FFP) and PCC. Patients received, pre CPB, either 2 units of FFP or half of the calculated PCC dose. Post-bypass, they received 2 more units of FFP or the second half of PCC dose. They noted that reversal with PCC was faster and bleeding was less.31