NOACs in Surgery

This a video from the European Society of Intensive  Care Medicine on monitoring , time of holding and restarting of NOACs in relation to surgery and treatment/reversal  with various degrees of bleeding. A couple of important points:

1) Apixaban does not affect coagulation parameters, as all other NOAC's do to a variable extend (but never correlate with degree of anticoagulant effect) . dTT and PT/PTT will only tell you if there is treatment effect if elevated, but it says nothing about the actual levels of the drug . A normal PT/PPT and TT in a patient taking an unknown NOAC , can have significant elevated drug levels and be coagulopathic when the drug was apixaban.
2) There is no role for a FFP during bleeding with any of these drugs ....you will have to give liters and liters and deplete the bloodbank in the process
3) Thromboelastograms will become more and more important, especially now that rivaroxiban is approved in conjunction with DAPT in ACS
4) Be very careful with NOACs in Stage D HFrEF patients, as they often have wide swings in renal function and a large number of them have cardio-renal syndrome class II. I still prefer VKA as drug of choice. Moreover, these patients were not studied in the various trials
5) Although not mentioned in this Webinar: NOAC's are contraindicated in patients with mechanical valves ( until further trials available)  !

Attached is also an article from JACC on the relation of NOAC's and coagulation parameters.

Laboratory Measurement of the Anticoagulant Activity of the Non–Vitamin K Oral Anticoagulants