What blood products should be reserved for a surgical patient on Apixaban (apixaban)?

Blood Products for Surgical Patients on Apixaban

For surgical patients on apixaban requiring emergency surgery or experiencing severe bleeding, prothrombin complex concentrate (PCC) at a dose of 50 IU/kg should be the primary blood product reserved, along with other blood components as clinically indicated. 1

Emergency Surgery Management Algorithm

Pre-operative Assessment

• Determine time of last apixaban dose
• Check baseline coagulation tests (though standard tests have limited utility)
• Assess renal function (affects apixaban clearance)
• Evaluate bleeding risk of procedure

Blood Products to Reserve

For Urgent/Emergency Surgery:

1. Prothrombin Complex Concentrate (PCC)

   • Reserve 50 IU/kg for immediate reversal 1, 2
   • Four-factor PCC preferred over three-factor PCC 2
   • Administer if surgery cannot be delayed for at least 24-48 hours after last apixaban dose

2. Blood Components

   • Packed Red Blood Cells (PRBCs) - for hemoglobin maintenance
   • Fresh Frozen Plasma (FFP) - as alternative if PCC unavailable 1
   • Platelets - reserve for patients with thrombocytopenia or on concurrent antiplatelet therapy

For Active Bleeding During Surgery:

• Moderate Bleeding: Consider delaying additional doses of apixaban 1
• Severe/Life-threatening Bleeding: Administer PCC 50 IU/kg 1

Severity-Based Management

Minimal Bleeding

• Delay next apixaban dose
• Local hemostatic measures
• No specific blood products typically needed

Moderate Bleeding

• Delay or discontinue apixaban
• Mechanical compression
• Volume support/maintain diuresis
• Consider absorption-activated charcoal if last dose taken within 2-4 hours 1

Severe/Life-threatening Bleeding

• PCC 50 IU/kg
• PRBCs as needed for anemia
• FFP as plasma expander if needed
• Platelets if thrombocytopenic or on antiplatelet drugs
• Consider tranexamic acid (1g bolus) to reduce bleeding 1

Important Considerations

Timing Considerations

• Apixaban should ideally be discontinued 3 days before major elective surgery or neuraxial blockade, especially in patients with renal dysfunction 1
• For other surgeries, apixaban can be stopped 24-48 hours before the procedure 1
• No bridging anticoagulation is required except in patients with recent (<3 months) history of venous thromboembolism 1

Monitoring Limitations

• Standard coagulation tests (PT, aPTT) have limited utility in assessing apixaban's anticoagulant effect 1, 3
• No specific routine coagulation test reliably determines apixaban effectiveness 1

Resumption of Anticoagulation

• Restart apixaban as soon as adequate hemostasis has been established 4
• For most procedures, apixaban can be resumed 24-48 hours postoperatively 5

Pitfalls and Caveats

1. Avoid FFP as first-line therapy - PCC is preferred due to higher concentration of clotting factors, less volume, and faster correction 1, 2

2. Recognize PCC thrombotic risk - PCCs carry risk of thrombotic complications; thromboprophylaxis should be initiated once bleeding is controlled 2

3. No specific antidote for apixaban - Unlike dabigatran (reversed by idarucizumab), apixaban-specific reversal agent andexanet alfa may not be widely available 1, 2

4. Avoid unnecessary reversal - Excessive reversal when INR is already normal may create a prothrombotic state 2

5. Consider renal function - While apixaban is less dependent on renal function than dabigatran, impaired renal function may still affect clearance 1

By following this approach, clinicians can optimize the management of surgical patients on apixaban to minimize both bleeding and thrombotic risks.