Warfarin reversal: Difference between revisions
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==Background==
=Background=
#Vitamin K
#Vitamin K
##PO route for vit K is preferred to subq route due to superior efficacy
##Oral route is preferred over subcutaneous route: superior efficacy
##IV route carries rare but serious risk of anaphylaxis
##Intravenous route carries rare but serious risk of anaphylaxis
###Only give for pts with:
##Only give for patient with:
####Life-threatening bleeding
###Life-threatening bleeding
####INR >20
###INR >20
####Symptomatic pts poisoned by suicidal ingestion of warfarin or rodenticide
###Symptomatic patient poisoned by suicidal ingestion of warfarin or rodenticide
==Excessive Anticoagulation==
===INR < 5 No Bleeding===
#Lower dose or omit one dose
#Resume at lower dose once INR therapeutic


===INR 5-9 No Bleeding===
=Excessive Anticoagulation=
#Hold next 1-2 doses
==INR < 5 No Bleeding==
#Vit K 1-2.5mg po (only if pt is at high risk for bleeding)
#Give lower dose of warfarin or omit one dose of warfarin
##Age >75yr
#Resume warfarin at lower dose once INR therapeutic
##Concurrent antiplatelet drug use
##Polypharmacy
##Liver or renal disease
##Alcoholism
##Recent surgery
##Trauma
#Resume at lower dose once INR therapeutic


===INR > 9 No Bleeding ===
==INR 5-9 No Bleeding==
#Hold warfarin
#Omit next 1-2 doses of warfarin
#Vit K 2.5-5mg po
#Vitamin K 1-2.5 mg oral: if patient at ''high risk'' for bleeding
#INR will decrease in 24-48h
##''Age >75 years''
##''Concurrent antiplatelet drug use''
##''Polypharmacy''
##''Liver or kidney disease''
##''Alcoholism''
##''Recent surgery''
##''Trauma''
#Resume warfarin at lower dose once INR therapeutic


===Life-Threatening Bleeding===
==INR > 9 No Bleeding ==
#Hold warfarin
#Stop warfarin
#Give Prothrombin complex concentrate or factor VII
#Give Vitamin K 2.5-5 mg po: INR will decrease over 24-48 hours
#Vitamin K
 
##Give if PCC nor factor VII are available
==Life-Threatening Bleed==
##10mg slow IV push (may repeat in 12hr if INR still elevated)
#Stop warfarin
#Give 4-factor Prothrombin Complex Concentrate (PCC) or 3-factor PCC + recombinant factor VIIa
#Give Vitamin K if PCC or factor VII not available
##10mg slow IV push: may repeat in 12 hours if INR still elevated
##May induce unwanted thrombosis and/or overcorrection
##May induce unwanted thrombosis and/or overcorrection
#FFP
#Give IV Fresh Frozen Plasma (FFP) 10-15 mL/kg: for 70 kg patient, 3 units = 750 ml
##Administer 10-15mL/kg (typically 3-4units)


==See Also==
==See Also==

Revision as of 19:17, 24 August 2013

Background

  1. Vitamin K
    1. Oral route is preferred over subcutaneous route: superior efficacy
    2. Intravenous route carries rare but serious risk of anaphylaxis
    3. Only give for patient with:
      1. Life-threatening bleeding
      2. INR >20
      3. Symptomatic patient poisoned by suicidal ingestion of warfarin or rodenticide

Excessive Anticoagulation

INR < 5 No Bleeding

  1. Give lower dose of warfarin or omit one dose of warfarin
  2. Resume warfarin at lower dose once INR therapeutic

INR 5-9 No Bleeding

  1. Omit next 1-2 doses of warfarin
  2. Vitamin K 1-2.5 mg oral: if patient at high risk for bleeding
    1. Age >75 years
    2. Concurrent antiplatelet drug use
    3. Polypharmacy
    4. Liver or kidney disease
    5. Alcoholism
    6. Recent surgery
    7. Trauma
  3. Resume warfarin at lower dose once INR therapeutic

INR > 9 No Bleeding

  1. Stop warfarin
  2. Give Vitamin K 2.5-5 mg po: INR will decrease over 24-48 hours

Life-Threatening Bleed

  1. Stop warfarin
  2. Give 4-factor Prothrombin Complex Concentrate (PCC) or 3-factor PCC + recombinant factor VIIa
  3. Give Vitamin K if PCC or factor VII not available
    1. 10mg slow IV push: may repeat in 12 hours if INR still elevated
    2. May induce unwanted thrombosis and/or overcorrection
  4. Give IV Fresh Frozen Plasma (FFP) 10-15 mL/kg: for 70 kg patient, 3 units = 750 ml

See Also

Source

Tintinalli

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