This post contains links to and excerpts from Dr. Josh Farkas’ outstanding Internet Book Of Critical Care [Link to the Table of Contents] chapter on Anticoagulant Reversal [Link to the Chapter] [Link to Podcast].
Here are excerpts:
- A common error is trying to reverse warfarin with PCC or FFP alone. If either of these is given without simultaneous vitamin K, it will wear off over several hours.
- For serious bleeding, vitamin K should be given intravenously (NOT im, sq, or orally).
- Vitamin K should never be given subcutaneously (erratic absorption) or intramuscularly (risk of hematoma).
- Beware of patients on NOACs who develop renal failure, but keep on taking their NOACs. They may accumulate drug and become severely supratherapeutic, without any screamingly abnormal lab values (unlike, for example, the patient on warfarin with an INR of 9 – who is quite obviously supratherapeutic).
- Aggressive reversal of anticoagulation prior to minor procedures (e.g. ultrasound-guided central line placement in a patient with a gigantic, superficial internal jugular vein).
- Don’t try to correct the pre-procedure INR to <1.7 using FFP – this is impossible and dangerous.
- U. Wisconsin Anti-thrombotic Reversal Guideline (last revised 1/2018)
- EMCrit Podcast 203 – New Reversals for New Anticoagulants with Nadia Awad
- Fixed-dose protocol for PCC dosing (PharmD blog, by Scott Dietrich)
- Adnexanet Alfa:
And here are the direct links from the chapter to the IBCC subject headings]: