The use of DOACs for the prevention of stroke and venous thromboembolism is increasing.
Though DOACs may be non-inferior to warfarin for these indications, it is important to consider the following pearls on DOACs in the critically ill patient:
Acute kidney injury can double the half-life of dabigatran to more than 30 hours
Hepatic failure can markedly increase the half-life of the factor Xa inhibitors
PT, aPTT, and INR may not accurately assess the risk of bleeding. Use dilute thrombin time (TT), ecarin clotting time (ECT), or TEG/ROTEM to assess coagulopathy
Can consider PCC (25 to 50 IU/kg) for life-threatening hemorrhage. The evidence supporting this recommendation is not robust.
References
Stensballe J, Moller MH. Ten things ICU specialists need to know about direct oral anticoagulants (DOACs). Intensive Care Med. 2018: epub ahead of print.
