Anti-platelet agent reversal: Difference between revisions

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==Sources==
==Sources==
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[[Category:Trauma]][[Category:Surgery]][[Category:Heme/Onc]]
[[Category:Trauma]][[Category:Surgery]][[Category:Heme/Onc]]

Revision as of 18:21, 22 May 2016

Background

  • Consider reversal of aspirin and clopidogrel in acute life threatening hemorrhage, primarily ICH[1]
    • Risk of mortality from ICH on warfarin ~16-80%
    • Significantly higher mortality with either clopidogrel mono or dual-antiplatelet tx in trauma pts[2]
    • Aspirin alone is predictor of higher mortality in spontaneous ICH[3]
  • Anti-platelet medications to reverse:
  • Platelet aggregation recovery[4]:
    • Within 4 days of stopping aspirin
    • Takes 10 days for clopidogrel (life-span of a platelet)
      • When starting clopidogrel, takes 7 days to achieve max platelet inhibition[5]
      • If 350 mg loading dose, plt inhibition occurs within 2-5 hrs

Reversal

  • If time permits, obtain initial platelet function assay for aspirin and clopidogrel
  • Reversal with combination of platelet transfusion, desmopressin
  • Limited evidence to support mortality improvement in reversal, but little evidence of harm[6]
  • Platelet transfusion volume:
    • At least 5 units of platelets initially to reverse routine antiplatelet doses[7]
    • Consider significantly more platelets for those who were loaded with clopidogrel within the last week[8]
  • Desmopressin (DDAVP)[9]
    • 0.3 mcg/kg/dose in 50 cc NS over 30 min[10]
    • Quick onset of action, within 1 hr
    • Similar MOA to cryoprecipitate (increase factor VIII, vWF)
    • No transfusion complications of cryoprecipitate
    • However, effects only last up to 24 hrs, and tachyphylaxis limits efficacy repeated doses

Sources

  1. ↑ Ohm C, Mina A, Howells G, et.al. Effects of antiplatelet agents on outcomes for elderly patients with traumatic intracranial hemorrhage. J Trauma. 2005;58:518-22.
  2. ↑ Wong DK, Lurie F, Wong LL. The effects of clopidogrel on elderly traumatic brain injured patients. J Trauma. 2008;65:1303-8.
  3. ↑ Saloheimo P, Ahonen M, Juvela S, et.al. Regular aspirin-use preceeding the onset of primary intracerebral hermoorhage is an independent predictor for death. Stroke. 2006;37:129-33.
  4. ↑ Li C et al. Reversal of the anti-platelet effects of aspirin and clopidogrel. J Thromb Haemost. 2012 Apr;10(4):521-8.
  5. ↑ Vilahur G, Choi GB, Zafar MU et.al. Normalization of platelet reactivity in clopidogrel-treated subjects. J Thromb Haemost. 1997;5:82-90.
  6. ↑ Orlando Regional Medical Center. Department of Surgical Education. ANTIPLATLET AGENT REVERSAL IN ADULTS WITH TRAUMATIC INTRACRANIAL HEMORRHAGE. http://www.surgicalcriticalcare.net/Guidelines/TBI%20Antiplt%20Reversal%20Guideline%202012.pdf.
  7. ↑ Powner DJ, Hartwell EA, Hoots WK, et.al. Counteracting the effects of anticoagulants oand antiplatelet agents during neurosurgical emergencies. Neurosurgery. 2005; 57:823-31.
  8. ↑ Downey DM, Monsn B, Butler KL, et.al. Does platelet administration affect mortality in elderly headinjured patients taking antiplatelet medications? Am Surg. 2009;75(11):1100-3.
  9. ↑ Hedges SJ, Dehoney SB, Hooper JS, et.al. Evidence-based treatment recommendations for uremic bleeding. Nature Clin Prac. 2007;3(3):138-53.
  10. ↑ . Gratz I, Koehler J, Olsen D, et.al. The effect of desmopressin acetate on postoperative hemorrhage in patients receiving aspirin therapy before coronary artery bypass operations. J Thorac Cardiovasc Surg. 1992; 104:1417-22.
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