ANTICOAGULANT REVERSAL

Question 1

MANAGEMENT

Answer 1

INDICATION
1. Major Bleed
2. Hemodynamic Instability
3. Bleeding with hemoglobin drop ≥2 g/dL (≥20 g/L)
4. Administration of ≥2 units of packed red blood cells

MANAGEMENT

1. WARFARIN with elevated INR: Octaplex (PCC) 80mL (2000 U)
   10 mg Vit K IV
   Hold Warfarin
   Repeat INR

If bleeding persists OR INR does not meet goal within 30 min of infusion, additional 500 U

2. NOAC (Rivaroxaban / Apixaban / Edoxaban): Octaplex (PCC) 80mL (2000 U) +/- 10 mg Vit K IV if elevated INR
3. HEPARIN: 1 mg Protamine per 100 units of unfractionated Heparin
4. DABIGATRAN: idarucizumab 5 g IV
   fXa: andexamet, TXA
   Thrombocytopenia: platelet transfusion

GENERAL INVESTIGATIONS
1. CBC
2. PT/INR
3. aPTT

WARFARIN
1. PT/INR

DABIGATRAN
1. Thrombin Time
-Normal: Excludes clinically relevant levels.
-Prolonged: Does not discriminate between clinically relevant and insignificant levels.

2. Ecarin clotting time (if available)
   Normal: Most likely excludes clinically relevant levels.
   aPTT
   Normal: Usually excludes clinically relevant levels.

NOAC
1. Factor Xa Activity

UNFRACTIONATED HEPARIN
1. aPTT
Can be used to assess efficacy of protamine reversal.

LMWH
1. Anti-Xa Levels
2. Anti-Xa levels
Nomograms and goals are institution specific because of laboratory variability of tests.

Question 2

DOCUMENTATION

Answer 2

1. DETERMINE HOME ANTICOAGULANT MEDICATION
2. DOSE
3. TIME OF LAST INGESTION