Presentation on theme: "Rapid Reversal of Warfarin Therapy in Patients with Intracranial / Intraspinal Bleeding Mount Auburn Hospital Blood Bank, Emergency Department, Critical."— Presentation transcript:
1 Rapid Reversal of Warfarin Therapy in Patients with Intracranial / Intraspinal Bleeding Mount Auburn HospitalBlood Bank, Emergency Department, Critical Care, Neurosurgery, Hem-Onc, Quality and Safety
2 Clinical QuestionsWhat 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 BackgroundLife threatening bleeds in patients on wafarin - Timely reversal is IMPERATIVE!Current Treatment Options:FFPConcerns: Delayed treatment (thaw time), volume overload, inadequate correctionVitamin K IVConcerns: Length of onset timeProthrombin Complex Concentrate (PCC)Desmopressin (DDAVP)Increases levels of VWF and factor VIIINow Available
6 Main Points:PCC normalizes INR faster than FFPPCC is recommended for patients with life-threateningwarfarin related bleedingPCC, vitamin K IV, and FFP should all be available for thispatient population
7 PCC: What is it? Also called: Bebulin (the brand name) Factor IX complex concentrate and has high levels of factor II, IX and X (vit K dependent coag. Factors)Low level of factor VIIWorks by temporarily raising the levels of these clotting factorsAHA / ASA class IIb recommendationCost: $1500 / dose ($1 / IU)
9 Rapid Reversal of Warfarin Order-set Restricted to the ED, Critical Care, and ORIndications: Confirmed CT with Intracranial or Intraspinal hemorrhage with elevated INRExclusions: HIT in previous 3 monthsRelative contraindications:DIC, history of recent thrombosis, MI, Ischemic Stroke
10 Initial Work-up STAT head CT Once Head CT confirmed: Notify/ CALL blood bank and core labBlood bank x 5096Core Lab x 5060Neurosurgical Emergency: Patient Name, and MR #All labs need to be handed to a lab techSTAT PT/INR, PTT, D-dimer, fibrinogen, CBC, in a bag labeled STAT to core labSTAT type and screen to blood bankSTAT BMP and LFTs
11 Next Steps (per order-set) 1) Immediately Administer Vitamin K 10 mg slow IV infusion2) Administer PCC (Bebulin)INR < ml Bebulin IV (~ 500 IU)INR > ml Bebulin IV (~ 1000 IU)Rate: Do not exceed 2 ml per minute IV3) 2 units FFP given4) Consider Plt if Plt < 100,0005) Consider DDAVP (Desmopressin) - If plt dysfunction present
12 Post Initial PCC infusion Follow up Labs: min AFTER PCC infusion is complete: STAT PT / INRGoal: Normalization of INR with in shortest time possibleFurther management: Per attending MDAdditional labs may be needed per the pathologist or MDMaximum I.U. per Medical Director of blood bank (~ 3000 IU maximum)
13 Case Study71 yo M with sudden onset of a severe headache and blurred visionVitals: BP 200/90, HR 92, RR 14, Temp 98PMH: Afib, CAD, HTN, diabetesMedications:Warfarin 5mg dailyLopressor 25mg BIDLipitor 20mg dailyGlucaphage 10mg BID
14 Case Study ContinutedHead CT shows ICHNext Steps?
15 Conclusions Coagulopathy puts patients at high risk for ICH Vitamin K Effective, but slow onsetFFPEffective, but slow and risk of volume overloadPCC - is effective and fast actingOrder - set is available nowWhen given together Vit. K, FFP, and PCC can quickly normalize INR
19 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