Makindo Medical Notes.com

As a rule stop and reverse all Anticoagulants acutely if there is life-threatening bleeding. If unsure take senior advice.

Assessment

• Low thrombotic risk e.g. AF with low CHADS VASC
• High Thrombotic risk e.g. recurrent VTE, Metal heart valves, Stroke with AF, Antiphospholipid syndrome
• Get an urgent INR. Investigate the reason for the high INR.
• Drug interactions are most common

Major Bleeding on Warfarin

• Any bleeding in a patient on warfarin should be taken seriously. If INR is not elevated then bleeding may be due to other factors and warfarin reversal may not be appropriate. Consider an underlying pathological cause. If in doubt discuss with a senior doctor or Haematologist.
• Major bleeding is Limb or sight or life-threatening bleeding, or other active bleeding with haemodynamic compromise (BP <90 mmHg systolic, oliguria, >2g/dL haemoglobin drop)
• Four-factor prothrombin complex concentrate (PCC) 25-50u/kg (Beriplex) Round to nearest 500 units, maximum 5000 units Plus 5mg IV Vitamin K Recheck coagulation 15 minutes after Beriplex If inadequate correction, consider other factors such as DIC, liver disease or inadequate Beriplex dose If adequate correction repeat testing at 4-6 hours

NON Major Bleeding on Warfarin

• Give 1-3mg IV Vitamin K Recheck INR daily until stable, or at 6 hours if bleeding continues Intravenous vitamin K produces a more rapid correction of the INR than oral Vitamin K and should be used in preference in the bleeding patient

NO Bleeding INR 5-8

• Omit warfarin until INR <5 and reduce maintenance dose Consider 1mg vitamin K PO if high bleeding risk e.g. age > 70 years, uncontrolled hypertension, liver disease, renal impairment, previous bleeding, recent surgery, anti-platelet drugs or thrombocytopenia Recheck INR daily until stable

NO Bleeding INR > 8

• Omit warfarin until INR <5 and reduce maintenance dose
• 1-5mg PO Vitamin K. Recheck INR daily until stable

New Neurology on Warfarin

• In patients with rapid onset neurological signs while on warfarin perform an URGENT INR and CT scan (within 1 hours).
• Consider urgent reversal with Beriplex while these results are awaited if high suspicion of intracranial bleeding

Warfarin and needs Surgery

• For surgery that requires reversal of warfarin and that can be delayed by 6-12 hours, the INR can be corrected by giving intravenous Vitamin K.
• For surgery that requires reversal of warfarin and which cannot be delayed, the
• INR can be corrected by giving PCC and intravenous vitamin K.
• Prothrombin complex concentrate (PCC) may induce a prothrombotic state. Use with caution in patients with DIC or decompensated liver disease

British Committee for Standards in Haematology 2011 Guidelines

• All hospitals managing patients on Warfarin should stock a licensed four-factor Prothrombin Complex Concentrate (PCC)
• Emergency anticoagulation reversal in patients with major bleeding should be with 25-50 u/kg four-factor Prothrombin Complex Concentrate (PCC) and 5 mg IV Vitamin K
• Recombinant factor VIIa is not recommended for emergency anticoagulation reversal
• Fresh frozen plasma produces suboptimal anticoagulation reversal and should only be used if Prothrombin Complex Concentrate (PCC) is not available
• Anticoagulation reversal for non-major bleeding should be with 1-3 mg IV Vitamin K. Patients with an INR >5 but who are not bleeding should have 1-2 doses of Warfarin withheld and their maintenance dose should be reduced. The cause of the elevated INR should be investigated
• Patients with an INR >8 should receive 1-5 mg of oral Vitamin K
• For surgery that requires reversal of Warfarin and that can be delayed for 6-12 h, the INR can be corrected by giving IV Vitamin K. For surgery that requires reversal of Warfarin and which cannot be delayed, for Vitamin K to have time to take effect the INR can be corrected by giving PCC and IV Vitamin K. PCC should not be used to enable elective or non-urgent surgery
• All patients on Warfarin presenting to Accident and Emergency departments with a head injury should have their INR measured as soon as possible
• A lower threshold for performing a head CT scan should be used for patients on Warfarin
• Patients on Warfarin presenting with a strong suspicion of intracerebral bleed should have their anticoagulation reversed before the results of any investigations

Bleeding due to UFH heparin

• STOP HEPARIN: Check FBC, Platelets, APTT
• If bleeding is excessive or uncontrolled:
• Consider reversal by administration of protamine sulphate injection by slow intravenous injection (max rate 5 mg/min) over a period of >5 minutes
• Calculate Protamine dose based on the quantity of UFH administered in the previous 2 hours (1 mg protamine sulphate neutralizes 80–100 units of UFH)
• Otherwise Heparin excess will correct in a few hours

Significant Bleeding due to LMWH

• Stop LMWH. Check FBC, coagulation screen and request FFP
• If within 8h of LMWH administration consider reversal with protamine sulphate over a period of >5 mins (1mg per 100 anti Xa units)
• If ineffective, consider further protamine sulphate 0.5 mg per 100 anti-Xa units
• Consider rFVIIa if there is continued life-threatening bleeding despite protamine sulphate and the time frame suggests LMWH maybe contributing to bleeding.

Bleeding with Thrombolysis

• Alteplase, tenecteplase, reteplase, urokinase and streptokinase.
• All five agents function indirectly by promoting generation of plasmin, which then mediates clot lysis.
• Major bleeding (i.e. intracerebral) within 48 hours of administration of a fibrinolytic drug

Management

• Stop infusion and any other anti-thrombotic drugs
• Administer FFP 12ml/kg and IV Tranexamic acid 1g TDS
• If low Fibrinogen administer cryoprecipitate or fibrinogen concentrate
• Cryoprecipitate contains fibrinogen, factor VIII/von Willebrand factor, and factor XIII; 10 units will raise the fibrinogen by 0.7 g/L in the average-sized adult

References

• ANTICOAGULATION RELATED BLEEDING - GUIDELINE SUMMARY NHS Cornwall
• Guidelines on oral anticoagulation with Warfarin. British Committee for Standards in Haematology 2011