Anticoagulation reversal Flashcards
(10 cards)
What are the key considerations when approaching anticoagulation reversal?
Assess coagulopathy: Critically ill patients often have multiple causes of bleeding; review labs & meds.
* Use TEG if INR may be unreliable (e.g., cirrhosis, DIC).
* Check all meds including OTC (e.g., aspirin).
* Low risk (e.g. AFib, DVT) → short interruption is okay. * High risk (e.g. mechanical mitral valve) → requires caution.
* Life-threatening bleeding → full reversal needed. * Minor bleeding → often local control is enough. * Mildly elevated INR often does not require reversal for minor procedures.
Common pitfalls with coagulopathy in ICU
Pitfalls to Avoid:
* Overestimating bleeding risk:
* Most bedside ICU procedures (except lumbar puncture) are low risk.
* Ignoring the bigger picture:
* Many ICU patients have multiple mild coagulopathies that add up.
* Overreliance on INR:
* INR interpretation is context-dependent.
* Example: INR 2.5 in cirrhosis ≠ INR 2.5 on apixaban.
* Trying to “normalize” INR to 1.0 with FFP:
* FFP is ineffective in patients with INR ≤ 1.7.
* In cirrhosis, FFP improves INR, not clinical hemostasis.
Best Practices:
* Recognize that most ICU procedures are low risk (e.g. per Society of Interventional Radiology).
* Take a comprehensive view: meds + labs + patient condition.
* Use TEG when in doubt—especially in:
* Cirrhosis
* Complex bleeding scenarios
* To assess need for factor replacement more accurately than INR
Pre-Procedure Coagulation Management
General Principles
- No specific lab threshold ensures safety for procedures (e.g., platelet count, INR).
*Guidelines vary widely on platelet thresholds for central lines (>50, >30, >20, >10 x10⁹/L). - Decisions should be individualized, based on overall bleeding risk and clinical context.
- Avoid routine use of prophylactic blood products unless clearly indicated.
Procedural safety
Thoracentesis
Key- to avoid arterial puncture
#Central Line Insertion
* Performed by experienced operator with ultrasound guidance.
* Proceed only if there’s a favorable ultrasound view:
* Clear vein visualization.
* Clear separation from artery.
* Technical considerations:
* Use a shallow angle of needle approach.
* Avoid backwalling (don’t puncture through both sides of the vessel).
* Avoid near the spine—artery position is more variable. * Stay close to the upper edge of the rib to avoid intercostal vessels. * Use ultrasound to: - Visualize and avoid intercostal arteries. - Maintain continuous negative suction during syringe advancement. - If arterial blood appears, stop immediately.
* Use a small-bore needle (e.g., 24G LP needle without stylet). * Use ultrasound with Doppler to: - Identify and avoid inferior epigastric arteries. Trauma to these arteries can cause massive hemorrhage.
Warfarin reversal
For lifethreatening bleeding
1. Hold dose
2.Vitamin K-10mg IV
3. PCC - prefered option(25mg/kg)
4. FFP if PCC not available- both work for approx 8hrs
%. Flollow up with repeat INR
Dabigatran
- Monitoring- TT- normal TT rules out significant Dabigatran toxicity
*Reversal- Idariucizumzb- monoclonal Ab Fab fragment that binds Dabigatran
-Dialysis if Praxabind not available
-PCC
Indications for reversal:
-Planned high risk procedure
- Life threatening/ intracranial bleed
SE of Idaricizumab:
-Rebound toxicity due to redistribution- rare–may consider repeat dosing
-Hypokalemia
-pyrexia
-Delerium
Xa inhibitors (rivaroxaban, apixaban, edoxaban, fondaparinux):
- Crude assay: INR
- Normal INR argues against a significant drug level but does not fully exclude it.
- Better assay: Anti-Factor Xa level
- Correlates well with drug level.
- Normal result excludes clinically relevant Xa inhibitors.
- Anti-Xa assay optimized for LMWH may be more sensitive.
- Best assay: Specific apixaban level.
Reversal:
* 1st-line: 4-factor PCC (Beriplex).
* Activated charcoal (50g) if
ingestion <2 hours ago.
* Vitamin K 10 mg IV if INR elevated (to rule out vitamin K deficiency).
* Andexanet alfa may be considered:
-Not available in Australia
- Very expensive.
-Mixed clinical data.
Apixaban assay
Indications
* Active bleeding.
* Need for emergent/urgent procedure.
* Suspected altered pharmacokinetics (e.g., elderly, renal impairment, drug interactions).
* Breakthrough thrombosis.
* Suspected non-adherence.
Limitations
* False elevation with:
* Heparins (UFH/LMWH), fondaparinux, other Xa inhibitors.
False depression with:
- Hemolysis (free Hb >50 mg/dL).
- Hypertriglyceridemia (>360–500 mg/dL).
- Bilirubin >6 mg/dL.
Thrombolytics (e.g., tPA/alteplase):
Essential Interventions
* Antifibrinolytics:
* Tranexamic acid: 1 g IV bolus → 1 g over 1 hr infusion.
OR * Aminocaproic acid: 4–5 g IV bolus → 1 g/hr infusion * Choose whichever is faster to access. * Cryoprecipitate: * Administer 10 units initially (or two 5-unit pools).
Optional Interventions
* Fresh Frozen Plasma (FFP): ~2 units may help with fibrinogen degradation.
* Platelets: Consider if bleeding is severe, platelet count is borderline, or patient is on antiplatelet therapy.
Follow-Up Care
* Repeat: CBC, INR, PTT, fibrinogen, and ideally TEG.
* Fibrinogen goal:
* 150–200 mg/dL (or >200 for intracranial hemorrhage).
* 10 units of cryo = ~50 mg/dL fibrinogen increase.
* If TEG shows ongoing hyperfibrinolysis:
* Repeat antifibrinolytic therapy.
* If INR >1.6, consider more FFP.
* Treat thrombocytopenia as needed.
Antiplatelets
- Desmopressin (DDAVP) 0.3-0.4 ug/kg, infuse over 20-30 minutes.
2.Target higher Fibrinogne level- Platelets and Fibrinogen work in conjunction to form a clot - Platelet transfusion - generally avoided
