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Warfarin and bleeding


Learning objectives

  • Learning
  • Understand
  • Integrate
  • Reflect

As a rule stop and reverse all Anticoagulants acutely if there is life threatening bleeding. If unsure take senior advice.

Assessment
  • Low thrombotic risk e.g. AF with low CHADS VASC
  • High Thrombotic risk e.g. recurrent VTE, Metal heart valves, Stroke with AF, Antiphospholipid syndrome
INRAction
>1.5 and BleedingAssess bleed risk and stop Warfarin and consider Vitamin K and if bleeding severe or life threatening then consider Octaplex or Beriplex. All decisions need to take into consideration the risks of bleeding versus thrombosis and expert help is recommended
3.0-6.0Reduce dose or omit dose if bleeding risk increased. All decisions need to take into consideration the indications and risks and benefits of Warfarin treatment
6.0-8.0Stop until INR < 5.0. If there is anything other than minor bleeding give IV Vitamin K 2-5 mg slow IV. If there is life threatening bleeding then give IV Vitamin K 5 mg slow IV immediately and Octoplex/Beriplex (prothrombin complex concentrates) or FFP which will mean discuss with haematologists
Greater than 8.0Stop until INR < 5.0. If there is anything other than minor bleeding give IV Vitamin K 2-5 mg slow IV. If there is life threatening bleeding e.g. GI bleed, Intracranial bleed, Retroperitoneal bleed etc then give IV Vitamin K 5 mg slow IV immediately and octoplex/Beriplex or FFP which will mean discuss with haematologists
British Committee for Standards in Haematology 2011 Guidelines
  • All hospitals managing patients on Warfarin should stock a licensed four-factor Prothrombin Complex Concentrate (PCC)
  • Emergency anticoagulation reversal in patients with major bleeding should be with 25-50 u/kg four-factor Prothrombin Complex Concentrate (PCC) and 5 mg IV Vitamin K
  • Recombinant factor VIIa is not recommended for emergency anticoagulation reversal
  • Fresh frozen plasma produces suboptimal anticoagulation reversal and should only be used if Prothrombin Complex Concentrate (PCC) is not available
  • Anticoagulation reversal for non-major bleeding should be with 1-3 mg IV Vitamin K. Patients with an INR >5 but who are not bleeding should have 1-2 doses of Warfarin withheld and their maintenance dose should be reduced. The cause of the elevated INR should be investigated
  • Patients with an INR >8 should receive 1-5 mg of oral Vitamin K
  • For surgery that requires reversal of Warfarin and that can be delayed for 6-12 h, the INR can be corrected by giving IV Vitamin K. For surgery that requires reversal of Warfarin and which cannot be delayed, for Vitamin K to have time to take effect the INR can be corrected by giving PCC and IV Vitamin K. PCC should not be used to enable elective or non-urgent surgery
  • All patients on Warfarin presenting to Accident and Emergency departments with head injury should have their INR measured as soon as possible
  • A lower threshold for performing a head CT scan should be used for patients on Warfarin
  • Patients on Warfarin presenting with a strong suspicion of intracerebral bleed should have their anticoagulation reversed before the results of any investigations
References