Major or life threatening bleeding
- Intracranial bleed
- Retroperitoneal bleed/Intra-ocular bleed
- Muscle bleed, with compartment syndrome
- Pericardial bleed
- Active bleed with ↓BP or 3g fall in Hb
| Patients INR | Dose PCC |
|---|---|
| INR 2 - 3.9 | 25 IU / Kg |
| INR 4 - 6 | 35 IU / Kg |
| INR > 6 | 50 IU / Kg |
A single dose of Octaplex® should NOT exceed 3000 IU (i.e. 120 mL Octaplex®)
If the calculated dose exceeds 3000 IU, administer the 3000 IU, then repeat the INR and seek advice from haematology.
Please check INR 30 mins post PCC infusion.
Reversing
Reversing Dabigatran
Contact haematology SpR - re Idarucizumab.
Dabigatran is an oral direct thrombin inhibitor (DTI) licensed for stroke prevention in atrial fibrillation.
Unlike warfarin, the PT/INR response to Dabigatran is inconsistent and should not be measured.
The activated partial thromboplastin time (APTT) provides a qualitative measurement of the anticoagulant effect of Dabigatran. Knowledge of the time of last dose is important for interpretation of the APTT.
If a patient receiving Dabigatran presents with bleeding:
- Omit/delay next dose of Dabigatran
- Measure APTT and PT (consider DTI assay if available)
- Consider charcoal, with sorbitol, if within 2 h of ingestion
- Give TXA - 1 g IV if significant bleed (TXA infusion guide)
- Involve haematology team re Idarucizumab or PCC
- Maintain renal perfusion to aid excretion
- Dabigatran - low protein binding - removed by dialysis
Reversing Rivaroxaban (Xarelto®)
The PT/INR/APTT responses to Rivaroxaban are not reliable.
- Omit/delay next dose of Rivaroxaban
- If available, use Andexanet Alfa: adults only
- Consider charcoal, with sorbitol, if within 2 h of ingestion
- PCC at 50 IU/Kg (max 2000 IU)
Reversing LMWH
- Consider Protamine 10mg/1000iu heparin infused / LMWH to a max of 7.5ml (75mg)
Anticoagulant reversal - Summary
| Drug | Mech. of action | Half-life | Emergency Reversal |
|---|---|---|---|
| Warfarin | Vitamin K antagonist | 20-60 hours | Vitamin K 5g IV ± PCC 25-50 U/kg |
| DOACs | Mech. of action | Half-life | Emergency Reversal |
| Dabigatran | Thrombin inhibitor | 9 hours (renal fxn.) | TXA 1g IV ± Idaruciumab (€) 5g IV |
| Rivaroxaban | Factor Xa inhibitor | 9 hours (renal fxn.) | Andexanet or PCC 50 U/kg |
| Apixaban | Factor Xa inhibitor | Andexanet or PCC 50 U/kg | |
| Edoxaban | Factor Xa inhibitor | Andexanet or PCC 50 U/kg | |
| Antiplatelets | Mech. of action | Half-life | Emergency Reversal |
| Aspirin | Irreversibly inhibits COX1 | 5-7 days | Platelet transfusion (low-level evidence). Desmopressin (caution with contraindications and limited evidence in trauma) |
| Clopidogrel | Irreversible inhibits P2YI2 receptors | 5-7 days | Platelet transfusion (low-level evidence). Desmopressin (caution with contraindications and limited evidence in trauma) |
| Prasugrel | Irreversible inhibits P2YI2 receptors | 5-7 days | Platelet transfusion (low-level evidence). Desmopressin (caution with contraindications and limited evidence in trauma) |
| Ticagrelor | Irreversible inhibits P2YI2 receptors | 5-7 days | Platelet transfusion (low-level evidence). Desmopressin (caution with contraindications and limited evidence in trauma) |
| Dipyridamole | Phosphodiesterase inhibitor | 24 hours | Platelet transfusion (low-level evidence). Desmopressin (caution with contraindications and limited evidence in trauma) |