On one of my recent shifts, I met an alcoholic liver cirrhosis gentleman who was on an unknown "blood thinner." As he spoke to me, I hoped he would never come in as a trauma notification. I hope this never happens, but incase it does here's a refresher on anticoagulation reversal and a side note on those with liver cirrhosis.
Vitamin K Antagonists/ Coumadin
Limits synthesis of Factors II, VII, IX, X, and the anticoagulant proteins C and S
Reversal: 5-10 mg IV Vitamin K; Onset is 2-6 hours
Reversal: 10-15 ml/kg Fresh frozen plasma (FFP), which contains all coagulation factors in non-concentrated forms.
Be careful in HF patients; because of the large volumes needed of this drug it can significantly increase intravascular volume
Usually people do 2U FF for ICH and 4U FFP for extracranial hemorrhages
Reversal: 4 Factor Prothrombin Complex Concentrate (PCC) =Kcentra contains factor VII, and non- activated factor II, IX, and X. Proteins C and S are also mixed in.
Initial dose 25-50 IU/kg for significant bleeds
In patients with concern for increasing intravascular volume, PCC (although costly) is less volume
Faster time to INR reversal
Direct Thrombin Inhibitors (DTIs)
Dabigatran (Pradaxa), Argatroban, Ximelagatran...
Inhibits both free thrombin and clot bound thrombin
Reversal: No specific agents, however transfusion of PRBCs and FFP is recommended. PCC could be helpful, but no definitive evidence yet.
For Dabigatran only, hemodialysis has been recommended as it possesses low plasma protein binding properties and thus is easy to dialyze out.
Also, an antibody, Idarucizumab, has been created however costs $3500
Factos Xa Inhibitors:
Rivaroxaban (Xarelto), Apixaban (Eliquis), Fondaparinux (Arixtra)
Inhibits factor Xa
Reversal: No specific reversal agents
4 Factor PCC has shown some promising results
Second line reversal: TXA: 1 gm over 10 minutes and then 1 gm over the next 8 hours if 4 Factor PCC is ineffective
This is the quick and dirty reference, however there are many considerations such as patients with liver failure, time of last anticoagulation use, severity of bleed, compliance of patient to anticoagulation.
A bit about cirrhosis patients...
In patients with cirrhosis the provider may use the INR and PT to assess synthetic function of the liver but not to assess hemorrhagic risk.The evidence supports a “watchful waiting” approach to the transfusion of platelets and fresh-frozen plasma with a bedside assessment of the patient’s actual hemorrhagic risk.
INR is not entirely meaningless in the setting of cirrhosis, but rather it may function a bit like a D-dimer. If the INR is normal then coagulation is intact. However, if the INR is elevated, then it reveals NOTHING about coagulation.