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Comment & Response
February 2020

Epidural Catheter Use and Further Issues in Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant—Reply

Author Affiliations
  • 1The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, New York
  • 2Department of Medicine, McMaster University, Hamilton, Ontario, Canada
JAMA Intern Med. 2020;180(2):333-334. doi:10.1001/jamainternmed.2019.5851

In Reply In response to Pysyk’s inquiry about anesthesia use in our study,1 33% received general anesthesia, 8% received neuraxial anesthesia, and 55% in the other category received mostly local anesthesia/sedation. Use of postoperative continuous epidural analgesia was not documented but, as pointed out, coadministration of a direct oral anticoagulant (DOAC) with such analgesia is not recommended.2 Any surgery or procedure using neuraxial anesthesia was considered high bleed risk, with 2 days DOAC interruption, corresponding to a 60- to 68-hour interval between the last dose and surgery to allow sufficient time approximately 5 DOAC half-lives) for a minimal-to-no residual anticoagulant effect at surgery or procedure,3 resulting in 98.9% of patients with high bleed risk with DOAC levels less than 50 ng/mL.1

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