1. Rapid Reversal of Warfarin Therapy in Patients with Intracranial / Intraspinal Bleeding
Mount Auburn Hospital
Blood Bank, Emergency Department, Critical Care, Neurosurgery, Hem-Onc, Quality and Safety

2. Clinical Questions
What are the treatment options for anticoagulation reversal?
How fast do they work?
What are the risk factors?
What is the Rapid Reversal of Warfarin Order-Set?

3. Background
Life threatening bleeds in patients on wafarin - Timely reversal is IMPERATIVE!
Current Treatment Options:
FFP
Concerns: Delayed treatment (thaw time), volume overload, inadequate correction
Vitamin K IV
Concerns: Length of onset time
Prothrombin complex concentrate (PCC)
Desmopressin (DDAVP)
Increases levels of VWF and factor VIII
Now Available

4. Evidence for Use of PCC

5. Evidence continued

6. Main Points:
PCC normalizes INR faster than FFP
PCC is recommended for patients with life-threatening
warfarin related bleeding
PCC, vitamin K IV, and FFP should all be available for this
patient population

7. PCC: What is it? Also called: Kcentra
Replaces: factor II, VII, IX and X (vit K dependent coag. Factors)
Works by temporarily raising the levels of these clotting factors
AHA / ASA class IIb recommendation

9. PCC: Risk factors Allergic reaction DIC Thrombosis
Chills, headache, fever, nausea and vomiting, rash, anaphylactic reaction
If this occurs, stop infusion and treat with antihistamines
DIC
Thrombosis

10. Rapid Reversal of Warfarin Order-set
Restricted to the ED, Critical Care, and OR
Indications: Intracranial or Intraspinal hemorrhage with elevated INR
Exclusions: HIT in previous 3 months
Relative contraindications:
DIC, history of recent thrombosis, MI, Ischemic Stroke

11. Initial Work-up STAT head CT Notify blood back and core lab
Alert: Neurosurgical Emergency, Name, and MR #
STAT PT/INR, PTT, D-dimer, fibrinogen, CBC, in a bag labeled STAT to hematology
STAT type and screen to blood bank
STAT BMP and LFTs

12. Next Steps (per order-set)
Administer Vitamin K 10 mg slow IV
Administer PCC (Kcentra)
INR < IU of Kcentra IV
INR > IU of Kcentra IV
Rate: Do not exceed 5 ml per minute IV Push
Administer Platelets if Plt < 100,000
DDAVP (Desmopressin) - consider if plt dysfunction present

13. Administration of PCC Available from the Blood Bank
Needs to be reconstituted immediately prior to use
Does not contain a preservative and must be used within 3 hours of reconstitution
Do not refrigerate
Concentrate should be drawn up with the contents in the package obtained from the blood bank
Administer IV at a maximum rate of 5ml / min IVP

14. PCC IV Infusion How to prepare the medication Follow up Labs:
You will receive a kit from the blood bank
2 minute administration video available at:
Video listed under dosing and administration
Note: The website indicates a weight based dosing with the INR. The dosing at MAH will only be based on INR.
Follow up Labs:
PT/INR min after the infusion is complete

15. Case Study
71 yo M with sudden onset of a severe headache and blurred vision
Vitals: BP 200/90, HR 92, RR 14, Temp 98
PMH: Afib, CAD, HTN, diabetes
Medications:
Warfarin 5mg daily
Lopressor 25mg BID
Lipitor 20mg daily
Glucaphage 10mg BID

16. Case Study Continuted
Head CT shows ICH
Next Steps?

17. Summary Coagulopathy puts patients at high risk for ICH Vitamin K FFP
Effective, but slow onset
FFP
Effective, but slow and risk of volume overload
PCC - is effective and fast acting
Orderset is available now under “evidence and ordersets” on the portal
Orderset title: “Kcentra Rapid Reversal Warfarin”

18. References Chest 2008; 133 (6Suppl): 160S - 198S
Stroke 2007; 38;
Yasaka M et al; Optimal dose of PCC for acute reversal of oral anticoagulation. Thromb Res. 2005; 115;
Nat’l Advisory Committee on Blood and Blood Products, September 2008