Reversal of Anticoagulation in Intracerebral Hemorrhage

  • View
    392

  • Download
    0

Embed Size (px)

Text of Reversal of Anticoagulation in Intracerebral Hemorrhage

  • Reversing AnticoagulationIn Intracerebral Hemorrhage

    John PerezOctober 27, 2015

  • Todays outline:

  • The Basics

  • There are 4 steps to hemostasis

  • The coagulation cascade is a result of complex interactions between factorsaPTTPT/INR

  • The body balances anticoagulation and procoagulationProcoagulationAnticoagulationI, IIIII, IVV, VI, VII, VIIIIX, X, XI, XIIC, S, Antithrombin, Plasmin

  • Diseases upset the bodys balanceProcoagulationAnticoagulationAF, MI, DVT Heart ValvesDyscraciasEmbolismsStroke

  • Different drugs are used to restore balanceProcoagulationWarfarinHeparinAnti-PlateletsNOACsAF, MI, DVT Heart ValvesDyscraciasEmbolismsStrokeAnticoagulation

  • But too much drugs is a problem, tooProcoagulationAnticoagulationDiseaseAnti-PlateletsHeparinWarfarinNOACs

  • II. The Problems

  • Anticoagulants have potential risks for bleeding

  • Intracerebral hemorrhage has several etiologies

    ICH secondary to anticoagulation has an incidence of about 0.6-1% per year. Warfarin is said to double the mortality of ICH.*

  • Anticoagulation is double-bladedAnticoagulationProblems:Mortality ratesINR range

    InfarctHemorrhage

    Warfarin-associated ICH has double the mortalityBleeds can occur even at therapeutic levels of INR (2-3). Higher risk 3 or above.

    *

  • Aspirin was most frequently used in a cohort of 435 ICH patientsRosand et al. The Effect of Warfarin and Intensity of Anticoagulation on Outcome of ICH. Stroke. 2004

    Chart1

    0.317

    0.234

    0.051

    0.398

    Percent

    Sheet1

    Percent

    Aspirin31.70%

    Warfarin23.40%

    Both5.10%

    None39.80%

    To resize chart data range, drag lower right corner of range.

  • 57/MTricycle driver

    HTNCAD s/p MIAFMR

    On warfarinINR 2.6Mr. CU came in for loss of consciousness

  • III. The SolutionsWarfarin, Heparin and Special Cases

  • Goals of Emergent ManagementAggressively lower INR to normalAggressive BP controlVentriculostomy if indicatedFor rFVIIa: monitor ECG, troponinsFor FFP: monitor for congestionWijdicks and Rabinstein. Neurocritical Care. 2012

  • Management will rely on the underlying drug

  • Reversing Warfarin

  • Warfarin inhibits Vitamin K-dependent factors: II, VII, IX, X

    *

  • Vitamin K and FFP are used to reverse warfarin10mg IV15-20mL/kgover 90 minutesHemphill et al. Guidelines for Management of Spontaneous ICH. Stroke. 2015All clotting factors, anticoagulants, fibrinogen, proteins, electrolytes

  • Vitamin K and FFP have pros and consWijdicks and Rabinstein. Neurocritical Care. 2012

    Vitamin KFFPOnset of ActionSlow; depends on liver functionFastTime to PrepareFastSlowVolume RequiredLittlePlentyRisksAnaphylaxisInfection, anaphylaxis, transfusion reactions, congestion

  • PCC and rFVIIa are acceptable alternatives25-50 units/kg20-40mcg/kgWijdicks and Rabinstein. Neurocritical Care. 2012II, VII, IX, X, C, S

  • rVIIa induces activation of the extrinsic pathway

    *

  • PCC and rVIIa have advantagesWijdicks and Rabinstein. Neurocritical Care. 2012

    Vitamin KFFPPCCrVIIaOnsetSlow; depends on liver functionFastFastTime to PrepareFastSlowFastVolume RequiredLittlePlentyLittleRisksAnaphylaxisInfectionAnaphylaxisTransfusion reactionsCongestionExpensiveNot widely availableNot extensively studiedMyocardial Infarction

  • Close monitoring of INR is essentialTorbey. Neurocritical Care. 2012

  • ReversingHeparin

  • Heparin indirectly inhibits IIa and XaHeparin

  • Protamine sulfate renders heparin inert1mg per 100 units heparinFor LMWH: 1mg/1mg LMWHSIVP max rate of 5mg/minMax dose: 50mgHemphill et al. Guidelines for Management of Spontaneous ICH. Stroke. 2015

    Interval (mins)Dose (mg/100u heparin)30-600.5-0.7560-1200.375 0.5> 1200.25 to 0.375

  • Special Case 1: Platelet Disorders and Aspirin in ICHBroderick et al. Guidelines for Management of Spontaneous ICH in Adults. Stroke. 2007

  • Broderick et al. Guidelines for Management of Spontaneous ICH in Adults. Stroke. 2007Special Case 2: ICH after fibrinolyticsPoor prognosisPlatelet transfusionCryoprecipitate FibrinogenVIII, XIIvWF

  • Emergent reversal creates a new problemAnticoagulationTherapeuticHemorrhageInfarct

  • The decision to restart anticoagulation demands a hollistic assessmentBroderick et al. Guidelines for Management of Spontaneous ICH in Adults. Stroke. 2007Evaluate risk for:DVTPEMIRepeat ICHOverall neurologic status

  • 700mL FFPHow did we manage Mr. CU?10mg IV q6 x 4 dosesINR2.6 1.2 in 24 hours

  • What happened to Mr. CU?2nd HD: underwent bilateral ventriculostomySerial CT showed persistence of hydrocephalusWarfarin put on hold. INR trend: 2.6 1.21 1.09th HD: underwent VP shunting19th HD: family opted to THOC

  • Wrapping up todays session

  • Questions?

    ICH secondary to anticoagulation has an incidence of about 0.6-1% per year. Warfarin is said to double the mortality of ICH.*Warfarin-associated ICH has double the mortalityBleeds can occur even at therapeutic levels of INR (2-3). Higher risk 3 or above.

    *

    *

    *