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New direct oral anticoagulants (NOAC), inhibitors of factor IIa or Xa, are expected to be widely used for the treatment of venous thromboembolic disease, or in case of atrial fibrillation. Such anticoagulant treatments are known to be associated with haemorrhagic complications. Moreover, it is likely that such patients on long-term treatment with NOAC will be exposed to emergency surgery or invasive procedures. Due to the present lack of experience in such conditions, we cannot make recommendations, but only propose management for optimal safety as regards the risk of bleeding in such emergency conditions. In this article, only dabigatran and rivaroxaban were discussed. For emergency surgery at risk of bleeding, we propose to dose the plasmatic concentration of drug. Levels inferior or equal to 30ng/mL for both dabigatran and rivaroxaban, should enable the realization of a high bleeding risk surgery. For higher concentration, it was proposed to postpone surgery by monitoring the evolution of the drug concentration. Action is then defined by the kind of NOAC and its concentration. If the dosage of the drug is not immediately available, proposals only based on the usual tests, PT and aPTT, also are presented. However, these tests do not really assess drug concentration or bleeding risk. In case of severe haemorrhage in a critical organ, it is proposed to reduce the effect of anticoagulant therapy using a nonspecific procoagulant drug (activated prothrombin concentrate, FEIBA, 30-50U/kg, or non-activated 4-factors prothrombin concentrates 50U/kg). For any other type of severe haemorrhage, the administration of such a procoagulant drug, potentially thrombogenic in these patients, will be discussed regarding concentration of NACO and possibilities for mechanical haemostasis.

Few scientific evidences are available in the literature, and the methodologic quality of the studies is often under average. Nevertheless, the conclusions are the following. Nephrectomy, renal transplantation, open surgery of the lower urinary tract and lumbar or pelvic lymph nodes dissection are at high risk for thromboembolic events. Other open or endoscopic urological procedures are at low risk. The laparoscopic approach doesn't change the risk associated with the procedure itself. Thromboprophylaxis is recommended in high-risk procedures. There was no evidence to recommend starting the prophylaxis before more than after the procedure. The use of low molecular weight heparin is recommended for prophylaxis. It can be associated with compressive stockings. It is recommended to treat for around seven days after the procedure. In case of cancer surgery, prophylaxis could be needed for four to six weeks.

New direct oral anticoagulants (NOAC), inhibitors of factor IIa or Xa, are expected to be widely used for the treatment of venous thromboembolic disease, or in case of atrial fibrillation. Such anticoagulant treatments are known to be associated with haemorrhagic complications. Moreover, it is likely that such patients on long-term treatment with NOAC will be exposed to emergency surgery or invasive procedures. Due to the present lack of experience in such conditions, we cannot make recommendations, but only propose management for optimal safety as regards the risk of bleeding in such emergency conditions. In this article, only dabigatran and rivaroxaban were discussed. For emergency surgery at risk of bleeding, we propose to dose the plasmatic concentration of drug. Levels inferior or equal to 30ng/mL for both dabigatran and rivaroxaban, should enable the realization of a high bleeding risk surgery. For higher concentration, it was proposed to postpone surgery by monitoring the evolution of the drug concentration. Action is then defined by the kind of NOAC and its concentration. If the dosage of the drug is not immediately available, proposals only based on the usual tests, PT and aPTT, also are presented. However, these tests do not really assess drug concentration or bleeding risk. In case of severe haemorrhage in a critical organ, it is proposed to reduce the effect of anticoagulant therapy using a nonspecific procoagulant drug (activated prothrombin concentrate, FEIBA, 30-50U/kg, or non-activated 4-factors prothrombin concentrates 50U/kg). For any other type of severe haemorrhage, the administration of such a procoagulant drug, potentially thrombogenic in these patients, will be discussed regarding concentration of NACO and possibilities for mechanical haemostasis.

Unite de medecine vasculaire, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France UJF-Grenoble 1/CNRS TIMC-IMAG UMR 5525/Themas, 38041 Grenoble, France c Pole anesthesie-reanimation, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France d Service d’anesthesie-reanimation, Hotel-Dieu, AP–HP, 1, place du Parvis-Notre-Dame, 75181 Paris cedex 04, France e Pole d’hematologie transfusion, centre de biologie pathologie, boulevard du Professeur-Jules-Leclercq, 59037 Lille cedex, France f Laboratoire d’hemostase, 2 bis, boulevard Tonnelle, 37032 Tours cedex, France g Laboratoire d’hemostase-thrombose, CHUM hopital Notre-Dame, 1560 Sherbrooke Est, H2L 4M1, Montreal, Canada h Laboratoire d’hemostase speciale, hopital cantonal universitaire, 4, rue Gabrielle-Perret-Gentil, 1211 Geneve 14, Suisse i Service de cardiologie, hopital St-Antoine, 184, rue du Faubourg-Saint-Antoine, 75571 Paris cedex 12, France Department of anesthesiology and critical care, hopital universitaire, Valencia, Espagne Departement d’anesthesie-reanimation, hopital Cochin, AP–HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France l Laboratoire central d’hematologie, hopital Saint-Eloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France CRTH et centre des coagulopathies, hopital du Bocage, BP 77 908, 21079 Dijon cedex, France n Laboratoire d’hematologie, groupe hospitalier Hotel-Dieu Cochin, 1, place du Parvis-Notre-Dame, 75181 Paris cedex 04, France Groupe de recherche sur la thrombose, unite de recherche clinique, innovation et pharmacologie, hopital Nord, 120, avenue Albert-Raimond, 42055 Saint-Etienne cedex 2, France p Laboratoire d’hematologie, hopital Rangueil, CHU de Toulouse, 1, avenue du Pr-Jean-Poulhess, TSA 50032, 31059 Toulouse cedex, France

Coagulopathy during massive haemorrhage increases morbidity and mortality rates. The modalities of treatment by transfusion of fresh frozen plasma (FFP) are a matter of debate. According to most clinical practice guidelines, FFP administration is driven by coagulation tests but, in cases of massive transfusion, patient management may be delayed whilst awaiting results and thawing FFP. Several retrospective cohort studies of military or civilian multiple trauma casualties requiring massive transfusion (10 red blood cells (RBC) within 24h) have suggested that early use of FFP and high FFP:RBC ratios (approaching 1) might improve survival and lessen morbidity. However, the methodology of these studies is suboptimal. They are subject, in particular, to survival bias. Massive FFP transfusions can also lead to an enhanced incidence of transfusion-related acute lung injury (TRALI), acute respiratory distress syndrome (ARDS), and multi-organ failure. At the present time, it is clear that FFP transfusion should be initiated early with a high FFP:RBC ratio in massive bleeding associated with haemostatic abnormalities such as multiple trauma. This does not imply that such a recommendation can be extended to the correction of high blood loss in other situations such as scheduled surgery. Actually, very few patients are likely to derive benefit from a 1/1 FFP:RBC transfusion strategy. They are chiefly multiple trauma victims with haemorrhagic shock and cases of ruptured abdominal aortic aneurysm. In other patients, in order to minimize risks and costs, a more parsimonious FFP use policy remains the best option until evidence for the benefit of 1/1 FFP:RBC is demonstrated.