Post-extraction bleeding in a patient on apixaban
A 68-year-old man attends for extraction of an unrestorable 36. His medical history includes atrial fibrillation for which he takes apixaban 5 mg twice daily; his last dose was this morning, roughly 4 hours ago. He also takes ramipril and atorvastatin. His eGFR from last month is 52 mL/min/1.73 m² and he weighs 74 kg. Blood pressure today is 158/92 mmHg. The tooth is grossly carious with a mobile, inflamed buccal flap of tissue and a history of two episodes of swelling in the last three months. He is anxious and asks whether he should have stopped his tablet. You have 4-0 silk sutures, a haemostatic dressing, tranexamic acid mouthwash, and access to a duty oral and maxillofacial unit by telephone.
1. How would you plan the extraction with respect to his anticoagulant, and what would you do differently if the tooth proved very difficult to remove atraumatically?
Read the worked answer
Apixaban should not be stopped for a routine single extraction; the decision to interrupt would need to be made with his cardiologist or anticoagulation team and is not justified here. His renal function (eGFR 52) and age mean elimination is somewhat slowed, but a single simple extraction is within the range that can be managed without interruption provided local haemostatic measures are planned.
Plan: treat in the morning where possible, use an atraumatic technique with periotomes and elevators, avoid a lingual or buccal flap where it can be avoided, place a suture and a haemostatic dressing, and give tranexamic acid 4.8% mouthwash four times daily for 2–3 days with instructions not to rinse vigorously. Check his blood pressure is controlled; 158/92 is high enough to consider deferring until his GP has reviewed him, because uncontrolled hypertension increases bleeding risk. Warn him that oozing for 24–48 hours is normal and give written post-operative instructions and an emergency contact.
If the tooth is very difficult, stop and reassess rather than persisting with a traumatic elevation. A surgical approach with a small flap and sectioning is acceptable, but if bleeding becomes difficult to control, pack, suture and refer the same day. If he had missed several doses and his INR-equivalent or anti-Xa level were unknown, or if he had recently had a bleed, telephone the oral and maxillofacial unit before proceeding.
2. He returns 6 hours later with continuous bleeding that has soaked through two gauze packs. Describe your immediate assessment and management, including what you would tell him about his medication.
Read the worked answer
Assess airway, breathing and circulation first, then estimate blood loss and check for pallor, tachycardia and postural symptoms. Take a focused history: did he rinse, suck, or exercise; has he taken further apixaban doses; is he on any other antiplatelet or NSAID. Examine the socket with good lighting and suction to find whether bleeding arises from soft tissue margins or from a bony vessel, and remove the clot to identify the source.
Management: infiltrate local anaesthetic with adrenaline, curette any granulation tissue, place a haemostatic dressing such as oxidised cellulose or a collagen sponge into the socket, and suture with a figure-of-eight or interrupted 4-0 silk under tension. Apply firm pressure with a gauze pack for 20 minutes and observe before discharge. If bleeding persists, re-pack and consider a tranexamic acid-soaked pack. Check blood pressure again; if it is markedly raised, that is a contributing factor and should be communicated to his GP.
Tell him not to stop or alter his apixaban himself, that the bleeding is from the socket and not a sign his heart medication is wrong, and to return or attend the emergency department if bleeding restarts and does not settle with 20 minutes of pressure. Refer to the oral and maxillofacial unit the same day if bleeding cannot be controlled in primary care, if he is haemodynamically compromised, or if there is a suggestion of a bleeding disorder.