Direct new oral anticoagulants (NOACs) - inhibitors of thrombin or factor Xa - 
are intended to be used largely in the treatment of venous thromboembolic 
disease or the prevention of systematic embolism in atrial fibrillation, instead 
of vitamin K antagonists. Like any anticoagulant treatment, they are associated 
with spontaneous or provoked haemorrhagic risk. Furthermore, a significant 
proportion of treated patients are likely to be exposed to emergency surgery or 
invasive procedures. Given the absence of a specific antidote, the action to be 
taken in these situations must be defined. The lack of data means that it is 
only possible to issue proposals rather than recommendations, which will evolve 
according to accumulated experience. The proposals presented here apply to 
dabigatran (Pradaxa(®)) and rivaroxaban (Xarelto(®)); data for apixaban and 
edoxaban are still scarce. For urgent surgery with haemorrhagic risk, the drug 
plasma concentration should be less or equal to 30ng/mL for dabigatran and 
rivaroxaban should enable surgery associated with a high bleeding risk. Beyond 
that, if possible, the intervention should be postponed by monitoring the drug 
concentration. The course to follow is then defined according to the NOAC and 
its concentration. If the anticoagulant dosage is not immediately available, 
worse propositions, based on the usual tests (prothrombin time and activated 
partial thromboplastin time), are presented. However, these tests do not really 
assess drug concentration or the risk of bleeding that depends on it. In case of 
serious bleeding in a critical organ, the effect of anticoagulant therapy should 
be reduced using a non-specific procoagulant drug as a first-line approach: 
activated prothrombin complex concentrate (aPCC) (FEIBA(®) 30-50U/kg) or 
non-activated PCC (50U/kg). In addition, for any other type of severe 
haemorrhage, the administration of a procoagulant drug, which is potentially 
thrombogenic in these patients, is discussed according to the NOAC concentration 
and the possibilities of mechanical haemostasis.