Learning objectives
- Learning
- Understand
- Integrate
- Reflect
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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
INR | Action |
>1.5 and Bleeding | Assess 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 |
3.0-6.0 | Reduce dose or omit dose if bleeding risk increased. All decisions need to take into consideration the indications and risks and benefits of Warfarin treatment |
6.0-8.0 | Stop 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 8.0 | Stop 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