Care of the surgical patient—part 2: oral anticoagulants

Individuals living with comorbidities and complex healthcare needs who require surgical intervention can present with additional challenges for perioperative staff (Holt, 2012; Dhatariya et al, 2016; Keeling et al, 2016). It is imperative that these are addressed throughout the perioperative care continuum, in addition to the standard guidelines and care requirements for surgical patients, as discussed in part one of this two-part series (Robertson and Ford, 2020), to reduce the risk of further complications. To demonstrate some of these challenges, this article provides some supplementary information regarding patients who are prescribed oral anticoagulants and are undergoing a surgical procedure.

Anticoagulant therapy and its role in the treatment of cardiovascular disorders (people with atrial fibrillation and mechanical prosthetic heart valves) is well recognised (National Institute for Health and Care Excellence (NICE), 2020); however, there is now an increased awareness and acceptance of its use to treat and prevent stroke and thromboembolism, all of which have implications for patients who are undergoing surgery (Pavord and Webster, 2015; Douketis and Lip, 2019). If prescribed anticoagulants are continued during surgery or invasive procedures, the risk of bleeding increases and additional potential harm may occur from the use of regional anaesthetics, including epidurals; however, if they are stopped, further thromboembolisms may develop (Keeling et al, 2011). Therefore, for patients receiving anticoagulation therapy, perioperative management must be holistically tailored, dependent on the patient's current medication, international normalised ratio (INR), thromboembolism risk and the type of surgery/anaesthetic that the patient is scheduled to receive (Association of Anaesthetists of Great Britain and Ireland (AAGBI), 2016; Dubois et al, 2017). With recent developments in pharmacology, there is now a range of direct oral anticoagulants (DOAC), such as apixaban, dabigatran, edoxaban and rivaroxaban, which have a fast onset of action; however, this article will focus on vitamin K antagonists and heparin, as these are the most commonly used (McIlmoyle and Tran, 2018).