Upload
jeremy-benjamin
View
50
Download
0
Tags:
Embed Size (px)
DESCRIPTION
Emergency anticoagulant reversal. B Vigué, DAR, CHU Bicêtre. 1 to 2% of the population are prescribed VKA (Vitamin K Antagonist) - Annual incidence of hemorrhage is 4 to 13% [Hylek, Circulation, 2003] In France - PowerPoint PPT Presentation
Citation preview
Emergency Emergency anticoagulant reversalanticoagulant reversal
B Vigué, DAR, CHU Bicêtre
1 to 2% of the population are prescribed VKA (Vitamin K Antagonist)
- Annual incidence of hemorrhage is 4 to 13% [Hylek, Circulation, 2003]
In France 17139 admissions per year in Emergency Department (ED) for bleeding under VKA (Sié 2002).In 2 month in a french universitary ED: 198 major bleedings, 34 for intracranial bleedings
INR>5 : 150 to 450 cas in french county EDs
Risk for intracranial haemorrhage: 1% per year
VKA decreases thrombotic risk
- Cardiac Valves :
Stroke : 4% / patient - yearAspirine : 2,2% / patient - year
VKA : 1% / patient - year
- Auricular Fibrillation
Stroke around 4% / patient - year
- Phlebitis and pulmonary embolism
Risk of VKA therapy VKA increases the risk for intracranial bleeding 7 to 10 foldIncidence : 0.3 to 1% per yearMortality: 60%
VKA + intracranial haemorrhage expansion = 50% No VKA + intracranial haemorrhage expansion = 10%
Risk factors for bleeding under VKA
INR in over therapeutic zone (>4-5) HTAStarting treatment (first 3 month)
As soon as possible!!
FFP : fresh frozen plasma Risk of TRALI
PCC (Prothrombin Complex Factor) : 4 factors superior to FFPNo delay to normalize60 ml of PCC = 2000 ml of FFP But factor VII 1/2 life = 5-6 hours
Vitamin K : Delayed correction = 6 to 8 hours to be effective Which dose?Delayed correction
No randomized trial
Thromb Haemost, 1997, United Kingdom41 patients
Retrospective studyPCC : 25-50 U IX / kg vs FFP (800ml)Vitamine K in all cases (1-5 mg IV)
In 15 min : complete reversal for 28/29 patient with PCC and for 0/12 patients for PFC
60 ml PCC=
2000 ml of FFP
PCC superior to FFP for emergency reversal of VKA
Needing of effective availability in all hospitals
Administration «as soon as diagnostic confirmed»
Guidelines
PCC(20-30 UI/kg)
+
Vitamin K (5-10 mg)
In France : management of INR in over therapeutic zone in cas of bleeding (n=198)
Intravenous vitamine K alone = 44%Oral vitamine K alone = 5%Intravenous vitamin K = 41%PCC in association = 29%PCC alone = 7%FFP = 25%
Under dosing of PCC (15 UI/kg instead of 20-30)
Discrepancy between guidelines and reality (fear of thrombotic events, availability of product)
Sié, 2002
•PCCs are the most accurate solution to reverse anticoagulation
Fact and hypothesis
• Intracranial bleeding under VKA : 50% mortality during the first month
Stroke, 2001
Thromb Haemost, 1997
• Delayed management could impair the prognosis
“You wouldn't say that if you had seen a valve thrombosis”
• To evaluate the rapidity of correction of INR after administration of PCC during the managment of neurosurgical bleeding
Aim of the study
Methods
• Rapid intravenous administration (1 min) of two 2 doses of PCC (10 U/kg)
•Begining of surgical procedure immediately after
•Preparation of the operative room, installation of patient for craniotomy before any laboratory results or administration of PCC
•Laboratory study: PT and INR before infusions, between infusions, immediately after and 6 hours later
• Administration of oral vitamin K, 5 mg
• Inclusion criteria : patients under VKA admitted for intracranial bleeding requiring a neurosurgical procedure
Methods
Emergency situationBe aware of pressure Come back to real riskCome back to the basics
Create an emergency situation, a golden hourAll are involved; emergency physicians, surgeons, anaesthesists, nurses
•Preparation of the operative room, installation of patient for craniotomy before any laboratory results or administration of PCC
•Rapid intravenous administration (1 min) of two 2 doses of PCC (10 U/kg)
Methods
Dose of PCC: INR between 2 and 3,5 : administration of 10 to 20 UI/kg of factor IX to limit the thrombotic riskIn INR in over therapeutic zone, 20 to 30 UI/kg of factro IX (25 UI/kg =1 ml /kg of factor IX)
Administration:Rate of infusion slower than 4 ml/min : 68/4 = 17 mins !!
Do not wait for laboratory control of reversal!
•Laboratory study: PT and INR before infusions, between infusions, immediately after and 6 hours later
Methods
Do not wait for laboratory control of reversal! A race against time A place for bedside monitoring?
Methods
• Administration of oral vitamin K, 5 mg
Oral vitamin K , efficiency to reverse anticoagulation in 6 to 12 hous (Br J of Haematology, 2001)
Oral vitamin K, superior to sub-cutaneous vitamin K to reverse anticoagulation
(Ann Intern Med, 2001)
Oral vitamin K, equivalent to intravenous vitamin K to reverse anticooagulation
(Ann Intern Med, 2003)
Results
• 18 patients included
• 12 subdural haematoma, 6 intracerbral haematoma
• No thrombotic complication
• Outcome : 13 patients with GOS 1 to 1, 4 patients died (23%)
Sexe AgeReason for VKA GCS Volume Dose/kg GOS
1 F 80 FA 14 60 20,0 1
2 M 73 FA 9 80 22,5 2
3 M 81 FA 9 60 20,0 1
4 F 71 PHV 6 60 21,4 5
5 F 71 VTE 6 60 21,4 1
6 M 62 atherom 10 80 20,0 1
7 M 82 atherom 6 70 22,5 1
8 F 54 FA 7 60 25,0 2
9 M 58 PHV 3 80 20,0 510 F 86 AVC 6 60 30,0 211 F 70 FA 8 60 21,4 512 M 56 FA 14 80 28 113 F 73 FA 10 60 20 114 M 58 PHV 5 80 20 215 F 70 FA 14 80 20 116 M 62 VTE 5 70 25 317 M 78 PHV 13 70 25 118 F 86 VTE 5 60 22 5
admission 1 min 2 min 6-12 h
PT (%) 20±9 62±14 78±15 66±17PT (sec) 40±22 14±2 12±2 13±2
TCK (sec) 53±15 41±10 40±11 37±5TT (sec) 20±5 20±4 21±5 18±4
V (%) 111±25 107±25 109±23 111±25
II (%) 33±23 70±20 94±21 87±22VII+X (%) 15±10 57±15 78±17 65±30
Results
INR 3,95±1,611,39±0,271,18±0,151,34±0,27
Results
0
20
40
60
80
100
120
TP
(%
)
Temps
Arrivée 1 min 2 min 6h-12h
10UI/Kg PPSB 10UI/Kg PPSB
* *
*
Results
0
20
40
60
80
100
120
TP
(%
)
Temps
10UI/Kg PPSB 10UI/Kg PPSB
Arrivée 1 min 2 min 6h-12h
avec vitamine K
sans vitamine K
Results
10UI/Kg PPSB 10UI/Kg PPSB
INR
Time
Admission 1 min 2 min 6h-12h
with vitamin K
without vitamin K
0
1,5
3
4,5
6
7,5
Results
Progressive reinitiating of anticoagulation,
No thrombotic event
Discussion
• 23% patients died (30 to 60 % in our litterature analysis)• The gain of time improves the management of the urgent neurosurgery. No laboratory control are needed to begin the surgical procedure
•Think for vitamin K !!
Discussion
•Why PCC is not currrently used ?…
Conclusion (1/3)
• Ultra rapid reversal of anticoagulation without thrombotic events
• VKA reversal improves time to surgical procedure
• Outcome? Mortality?
Conclusion (2/3)
•There is no way to delay surgery•Life-threatening events •All urgent surgery (as peritonitis…)
• there is no way to delay the reversal of VKA•Lost time +++ if life-threatening bleedings : intracranial and others•Lost time +++ if major bleedings in EDs
Conclusion (3/3)
• Need of teaching program : fight against non scientific historic fears.
•Need of multicentric trials in France and Europen. Evaluate the acccuracy and the safety of PCC. Show PCC as an antidote
•As malignancy hyperthermia in anaesthesia care, organize the management of bleeding under VKA with standardized written procedure.
As soon as diagnosis confirmed
As soon as possible