Introduktion.  The use of direct oral anticoagulants is an important step in the search for the ideal anticoagulant drug. However, safe and effective antithrombotic therapy requires consideration of all the effects of the medications used, especially in anesthesiology and intensive care.

Aim.  To identify the common complications and adverse effects associated with the use of direct oral anticoagulants, as well as the anesthesiologist’s tactical approaches in managing bleeding risks during the perioperative period based on a review of the literature.

Materials and methods. The search for relevant literature was conducted in PubMed, Science Direct, Google Scholar, Scopus and Web of Science. The literature search was done using the keywords «direct oral anticoagulants», «dabigatran», «rivaroxaban», «apixaban», «edoxaban» in combination with «complications», «operation», «threat of bleeding».

Results. Direct oral anticoagulants (DOACs), including apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used for patients with atrial fibrillation, venous thromboembolism, and ischemic stroke. The range of conditions for which DOACs are prescribed continues to expand. For elective surgical procedures in patients on continuous DOAC therapy, a standardized perioperative management approach is applied, taking into account the procedure-related bleeding risk (minimal, low, moderate, or high). Patients undergoing procedures with a minimal bleeding risk may continue DOAC therapy or, if excessive bleeding is anticipated, may omit the dose on the day of the procedure. For patients scheduled for low- or moderate-risk procedures, DOACs are typically stopped one day before and resumed one day after surgery. For procedures with a high bleeding risk, DOACs should be discontinued two days before and restarted two days after the operation. In patients on DOACs with potentially life-threatening bleeding, general coagulation tests are not suitable for excluding clinically relevant DOAC levels; specific drug level assays should be used when available. In emergency situations, hemostatic treatment should begin without waiting for laboratory results. A plasma DOAC concentration of approximately 50 ng/mL is considered a threshold for “clinically significant” drug levels before urgent intervention. Reversal: For dabigatran, the specific antidote idarucizumab is recommended. For factor Xa inhibitors, andexanet alfa or prothrombin complex concentrates (PCC/aPCC) may be considered depending on context and availability. However, andexanet is not recommended prior to cardiac surgery because it inhibits the unfractionated heparin required for extracorporeal circulation. 

Conclusion.  In clinical practice, it is necessary to assess both bleeding and thrombosis risks, taking into account the use of DOACs, the time elapsed since the last dose, and the patient’s renal function.

Keywords: review direct oral anticoagulants, threat of bleeding, perioperative period, anesthesiology, intensive care.