Preoperative assessment guidelines
Preoperative management of prophylactic and treatment doses will be the same.
Minor elective surgery (where warfarin not discontinued currently) e.g. cataracts
Rivaroxaban may be continued, but at least 24 hrs should have elapsed since the last dose. Rivaroxaban can be taken 4 hours post procedure.
All other elective surgery
48 hours should have elapsed since the last dose i.e. two missed doses. This is a conservative approach but will allow regional anaesthesia where applicable.
Emergency surgery
24 hours post dose - emergency surgery is unlikely to be associated with significant increased risk of bleeding.
Within 24 hours - where bleeding is likely, haematology advice should be obtained.
Further caution may be required in the presence of significant renal impairment.
Emergency reversal
Discuss with haematology on call. Andexanet alfa is a specific reversal agent. Where unavailable, consider prothrombin complex and tranexamic acid.
Neuraxial anaesthesia
Requires risk benefit analysis, but routinely requires 48 hours omission.
Unless at particularly high risk of embolism, patients will not be routinely Enoxaparin bridged; this is based on the short duration without anticoagulation and the intermediate baseline risk of thromboembolic events.
Postoperatively, in view of high bioavailability and peak concentrations achieved in 2.5-5 hours post dose, Rivaroxaban, Edoxaban or Apixiban should not be restarted until haemostasis is guaranteed.