Treatments for reversing warfarin anticoagulation in patients with acute intracranial hemorrhage: a structured literature review

Bechtel, Brett F.; Nuñez, Timothy C.; Lyon, Jennifer; Cotton, Bryan A.; Barrett, Tyler W.

doi:10.1186/1865-1380-4-40

Cited by 43 publications

(25 citation statements)

References 44 publications

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“…Clearly we cannot answer it in relation to dengue patients due to lack of data but indirect evidence can be drawn by experiences with patients having intracranial haemorrhages who were on warfarin [4,5]. Even then, there are only expert recommendations (no trial evidence) that suggest restarting anticoagulation within 3–10 days in patients whose anticoagulation is mandatory [6].…”

Section: Discussionmentioning

confidence: 99%

Dengue hemorrhagic fever and severe thrombocytopenia in a patient on mandatory anticoagulation; balancing two life threatening conditions; a case report

et al. 2012

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BackgroundManaging a severe dengue infection is a challenge specially when complicated by other comorbidities. We report a patient with dengue haemorrhagic fever and spontaneous bleeding who required mandatory anticoagulation for a prosthetic mitral valve replacement. This is the first case report in published literature describing this therapeutic dilemma.Case presentationA fifty one year old Sri Lankan woman was diagnosed with dengue haemorrhagic fever with bleeding manifestations. During the critical phase of her illness, the platelet count dropped to 5,000/ɥl. She was also on warfarin 7 mg daily following a prosthetic mitral valve insertion. In managing the patient, the risk of bleeding had to be balanced against the risk of valve thrombosis without anticoagulation. Warfarin was withheld when the platelet count dropped to 100,000/ɥl and restarted when it recovered above 50,000/ɥl. The patient was off anticoagulation for 10 days.ConclusionsWe managed this patient with close observation and continuous risk benefit assessments of management decisions. However, experience with one patient cannot be generalized to others. Therefore, it is essential that clinicians share their experiences in managing such difficult patients.

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Section: Discussionmentioning

confidence: 99%

Dengue hemorrhagic fever and severe thrombocytopenia in a patient on mandatory anticoagulation; balancing two life threatening conditions; a case report

et al. 2012

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“…Protrombin kompleks konsantresi faktör II, VII, IX ve X ile protein C ve S içerir ve önerilen doz 25-50 IU/kg dır. Rekombinant faktör VIIa'nın ise INR'yi taze donmuş plazmaya göre daha kısa sürede düzelttiğini belirten çalışmalar olmasına rağmen, her iki ürünün de trombotik komplikasyonlara sebep olması ve hızla teminlerinin mümkün olmayışı kullanımlarını kısıtlamaktadır (10,11).…”

Section: Discussionunclassified

Pharyngeal Hematoma Secondary to Anticoagulant Therapy: Case Report

Kaya¹,

Ceylan²,

Kocak³

et al. 2012

Turk J Anesth Reanim

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Hematomas secondary to anticoagulant therapy, inducing upper airway obstruction, are mostly located in the retropharyngeal, sublingual, submandibular and, rarely, laryngeal space. Most are managed conservatively but sometimes endotracheal intubation and emergency tracheotomy are necessary. We report a case of asphyxia due to a pharyngeal hematoma secondary to warfarin use, admitted to the emergency service with cardiopulmonary arrest.A 48 year-old woman presented at the emergency service with sore throat and difficulty in swallowing in the morning. After evaluation of the oropharynx, she was referred to the ear-nose throat clinic. However, on the same day, she presented at the emergency service with cardiopulmonary arrest. Direct laryngoscopy revealed a posterior pharyngeal mass or hematoma. Repeated intubation attempts failed. Despite the application of a laryngeal mask, she could not be ventilated and an emergency tracheostomy was performed. In her medical history, it was learned that she was taking warfarin for mitral stenosis. INR values were unmeasurably high. Fresh frozen plasma and vitamin K treatment were started. A computed tomography scan of the neck and cranium revealed extensive cerebral edema and a lesion in the pharynx, not distinguishable between bleeding and tumor and almost completely obstructing the airway. On the second day, her renal function deteriorated and she developed hypernatremia. The patient died due to multiorgan failure on the 5 th day.In patients using anticoagulants and presenting with symptoms like sore throat, odynophagia, dysphagia and hoarseness, pharyngeal hematoma should be excluded. Early diagnosis increases the success of conservative treatment and can be life-saving by preventing prolonged airway attempts.

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“…5 Use of anticoagulant therapy increases the risk of developing ICH by 7-to 10-fold, and anticoagulation-associated ICH (AAICH) accounts for up to 19% of all ICH cases. 6,7 The mortality rate due to AAICH is high despite anticoagulant reversal and factor repletion therapy; it is as high as 42.3% to 67% even following prothrombin complex concentrate (PCC) therapy. [7][8][9] The high mortality rates may be driven, at least in part, by hemorrhage expansion, as AAICH is associated with greater expansion than spontaneous ICH.…”

Section: Instructions For Obtaining Creditmentioning

confidence: 99%

Section: Instructions For Obtaining Creditmentioning

confidence: 99%

“…6 In 2004, there were 31 million outpatient prescriptions for warfarin in the United States, a 45% increase over a 6-year period. 6 The approval of the targeted oral anticoagulant (OAC) therapies dabigatran etexilate, rivaroxaban, and apixaban portends both a wider use of oral anticoagulation and a growing clinical concern about best practices in AAICH management. 11 Both thrombotic events due to discontinuing anticoagulation therapy and bleeding complications due to not reversing anticoagulation increase morbidity and mortality in AAICH patients.…”

Section: Instructions For Obtaining Creditmentioning

confidence: 99%

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Race against the clock: Overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhage

Roux

Pollack

Milan

et al. 2014

JNS

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Patients receiving anticoagulation therapy who present with any type of intracranial hemorrhage—including subdural hematoma, epidural hematoma, subarachnoid hemorrhage, and intracerebral hemorrhage (ICH)—require urgent correction of their coagulopathy to prevent hemorrhage expansion, limit tissue damage, and facilitate surgical intervention as necessary. The focus of this review is acute ICH, but the principles of management for anticoagulation-associated ICH (AAICH) apply to patients with all types of intracranial hemorrhage, whether acute or chronic. A number of therapies—including fresh frozen plasma (FFP), intravenous vitamin K, activated and inactivated prothrombin complex concentrates (PCCs), and recombinant activated factor VII (rFVIIa)—have been used alone or in combination to treat AAICH to reverse anticoagulation, help achieve hemodynamic stability, limit hematoma expansion, and prepare the patient for possible surgical intervention. However, there is a paucity of high-quality data to direct such therapy. The use of 3-factor PCC (activated and inactivated) and rFVIIa to treat AAICH constitutes off-label use of these therapies in the United States. However, in April 2013, the US Food and Drug Administration (FDA) approved Kcentra (a 4-factor PCC) for the urgent reversal of vitamin K antagonist (VKA) anticoagulation in adults with acute major bleeding. Plasma is the only other product approved for this use in the United States.1 Inconsistent recommendations, significant barriers (e.g., clinician-, therapy-, or logistics-based barriers), and a lack of approved treatment pathways in some institutions can be potential impediments to timely and evidence-based management of AAICH with available therapies. Patient assessment, therapy selection, whether to use a reversal or factor repletion agent alone or in combination with other agents, determination of site-of-care management, eligibility for neurosurgery, and potential hematoma evacuation are the responsibilities of the neurosurgeon, but ultimate success requires a multidisciplinary approach with consultation from the emergency department (ED) physician, pharmacist, hematologist, intensivist, neurologist, and, in some cases, the trauma surgeon.

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Treatments for reversing warfarin anticoagulation in patients with acute intracranial hemorrhage: a structured literature review

Cited by 43 publications

References 44 publications

Dengue hemorrhagic fever and severe thrombocytopenia in a patient on mandatory anticoagulation; balancing two life threatening conditions; a case report

Dengue hemorrhagic fever and severe thrombocytopenia in a patient on mandatory anticoagulation; balancing two life threatening conditions; a case report

Pharyngeal Hematoma Secondary to Anticoagulant Therapy: Case Report

Race against the clock: Overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhage

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