Warfarin Reversal Education NAR - (PDF for slower connections)

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

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

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

Evidence for Use of PCC

Evidence continued

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

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 VII
• Works by temporarily raising the levels of
these clotting factors
• AHA / ASA class IIb recommendation
• Cost: $1500 / dose ($1 / IU)

PCC: Adverse Reactions
• Allergic reaction
• Chills, headache, fever, nausea and
vomiting, rash tx with antihistamines
– Anaphylactic reaction tx immediately
• Thrombosis (small risk factor)

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

Initial Work-up
• STAT head CT
• Once Head CT confirmed:
– Notify/ CALL blood bank and core lab
– Blood bank x 5096
– Core Lab x 5060
• Neurosurgical Emergency: Patient Name, and MR #
– All labs need to be handed to a lab tech
• STAT PT/INR, PTT, D-dimer, fibrinogen, CBC, in a
bag labeled STAT to core lab
• STAT type and screen to blood bank
• STAT BMP and LFTs

Next Steps (per order-set)
1) Immediately Administer Vitamin K 10 mg
slow IV infusion
2) Administer PCC (Bebulin)
– INR < 5 20ml Bebulin IV (~ 500 IU)
– INR > 5 40ml Bebulin IV (~ 1000 IU)
– Rate: Do not exceed 2 ml per minute IV
3) 2 units FFP given
4) Consider Plt if Plt < 100,000
5) Consider DDAVP (Desmopressin) - If plt
dysfunction present

Post Initial PCC infusion
• Follow up Labs: 10 - 15 min AFTER PCC
infusion is complete: STAT PT / INR
•Goal: Normalization of INR with in
shortest time possible
• Further management: Per attending MD
• Additional labs may be needed per the
pathologist or MD
• Maximum I.U. per Medical Director of
blood bank (~ 3000 IU maximum)

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

Case Study Continuted
• Head CT shows ICH
•Next Steps

Conclusions
• Coagulopathy puts patients at high risk for
ICH
• Vitamin K
– Effective, but slow onset
• FFP
– Effective, but slow and risk of volume overload
• PCC - is effective and fast acting
– Order - set is available now
• When given together Vit. K, FFP, and PCC
can quickly normalize INR

References
• Chest 2008; 133 (6Suppl): 160S - 198S
• Stroke 2007; 38; 2001 - 2023
• Yasaka M et al; Optimal dose of PCC for
acute reversal of oral anticoagulation.
Thromb Res. 2005; 115; 455 - 459
• Nat’l Advisory Committee on Blood and
Blood Products, September 2008