Rapid Reversal of Warfarin Therapy in Patients with

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: 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

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

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

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

Next Steps (per order-set) • Administer Vitamin K 10 mg slow IV • Administer PCC (Kcentra) – INR < 5 500 IU of Kcentra IV – INR > 5 1000 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

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 5 ml / min IVP

PCC IV Infusion • How to prepare the medication – You will receive a kit from the blood bank – 2 minute administration video available at: • www. kcentra. com • 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 10 - 15 min after the infusion is complete

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 5 mg daily – Lopressor 25 mg BID – Lipitor 20 mg daily – Glucaphage 10 mg BID

Case Study Continuted • Head CT shows ICH • Next Steps?

Summary • 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 – Orderset is available now under “evidence and ordersets” on the portal – Orderset title: “Kcentra Rapid Reversal Warfarin”

References • Chest 2008; 133 (6 Suppl): 160 S - 198 S • 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