Direct Oral Anticoagulant (DOAC) Perioperative Management
Determine when to stop and restart a direct oral anticoagulant (DOAC) around a procedure. Covers neuraxial, deep, and superficial regional techniques with renal function adjustment for dabigatran.
Based on: ASRA 2022 · ESC 2022
Input
DOAC perioperative flow: Procedure → Drug → Timing → Safety → Restart
CrCl not entered: most conservative timing will be applied (dabigatran: 120 h)
Select the inputs above to see recommendations
Clinical reasoning
A patient on rivaroxaban is scheduled for a spinal anesthetic tomorrow. Last dose was 48 hours ago.
Is it safe to proceed with the spinal anesthetic?
A patient on apixaban is scheduled for a quadratus lumborum (QL) block. The clinician assumes 24 hours is sufficient — it's just an abdominal wall block.
How much withhold time is required for this technique?
Overview
DOAC perioperative management for direct oral anticoagulants. Select the DOAC, renal function, and planned technique to determine when to stop, procedural safety, and when to restart.
Evidence Summary
Evidence basis
This tool applies ASRA 2022 (neuraxial and regional technique timing) and ESC 2022 (surgical bleeding risk context and general DOAC management).
- Strict-tier techniques (neuraxial, deep block): ASRA 2022 as primary reference
- Standard-tier techniques (superficial block, general anesthesia): ESC 2022 surgical bleeding logic
- Dabigatran: CrCl-dependent timing; Xa inhibitors: unified at 72 h (strict) regardless of CrCl
MVP scope
This tool covers DOACs only. Warfarin, DAPT, and SAPT are excluded.