Assessment of Oral Anticoagulant Reversal Strategies in Emergency Surgery: Insights from a Prospective Study

Introduction: The management of thrombotic risk in clinical medicine has been a longstanding challenge. Oral anticoagulants, specifically vitamin K antagonists (VKAs) like warfarin, have been used for over fifty years. However, VKAs present significant challenges such as frequent monitoring and dietary interactions. Direct oral anticoagulants (DOACs) were developed to address these limitations, offering simplified dosing and fewer interactions. Both VKAs and DOACs, however, pose challenges in managing major bleeding and urgent surgical interventions. Methods: This prospective study, conducted at Mohammed V Military Hospital in Rabat from January 2022 to January 2023, examined the clinical practice, efficacy, and safety of different treatment strategies in patients on oral anticoagulants (VKAs and DOACs) requiring emergency surgery within 24 hours of hospital admission. Inclusion criteria included being over 18 years of age, on anticoagulant therapy, and requiring emergency surgery. Patients were evaluated for bleeding before and after surgery, use of hemostatic agents, blood loss, transfusions, and adverse events. Results: A total of 69 patients were included, with 48 treated with VKAs and 21 with DOACs. The mean age was 63.8 years (range 36-78), with a mean age of 62.5 years (±10.2) for the VKA group and 66.7 years (±9.1) for the DOAC group (p = 0.44). There was no significant difference in delays to surgery between the VKA (68%) and DOAC (66.6%) groups for surgeries performed within 24 hours. Hemostatic treatment varied significantly, with more VKA patients receiving resh frozen plasma (77% vs. 52%) and more DOAC patients receiving prothrombin complex concentrates (48% vs. 23%). Bleeding complications were observed in 12.5% of VKA patients and 9.5% of DOAC patients. Thromboembolic events were observed in one patient within 30 days, specifically, a pulmonary embolism occurring on day 3 in a patient who underwent surgery for a hip fracture. The mortality rate ...