Perioperative Management

• Decision making regarding whether dabigatran needs to be held depends on type of surgery, renal function, and balance of bleeding versus thrombosis risk. The duration for withholding is based upon the estimated dabigatran half-life times 2 to 3 half-lives for low procedural bleeding risk and 4 to 5 drug half-lives for high procedural bleeding risk. If it is indicated, dabigatran should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding, and should be discontinued for at least 24 hours prior to elective surgery or invasive procedures with low bleeding risk or where the bleeding would be non-critical in location easily controlled. 
• In adult patients with CrCl >50mL/minute, discontinue therapy prior to surgery as above. In adult patients with CrCl < 50mL/minute, discontinue dabigatran therapy ~72-120 hours prior to surgery, or longer, depending on risk of bleeding.
• In pediatric patients with CrCl >80 mL/minute, discontinue therapy 24 hours prior to elective surgery with low bleeding risk, or 48 hours prior to elective surgery with moderate or high bleeding risk.
• In pediatric patients with CrCl 50-80 mL/minute, discontinue therapy 48 hours prior to elective surgery with low bleeding risk, and >72 hours prior to elective surgery with moderate or high bleeding risk. 
• Epidural or spinal hematomas have occurred in patients treated with DOACs who are receiving neuraxial anesthesia or undergoing spinal puncture. Optimal timing between the administration of dabigatran and neuraxial procedures is not known. Consider holding for 24-72 hours prior to lumbar punctures for these reasons above.
• In rare cases, in patients with very high risk of thrombosis, bridging with unfractionated heparin may be required to limit the time off anticoagulation.
• Restart dabigatran after the procedure as soon as adequate hemostasis has been established and once cleared by the surgeon or interventionalist. If oral medication cannot be taken after the procedure, consider switching to a parenteral anticoagulant.