234. Anticoagulants, Antiplatelet Agents, and Fibrinolytics

TEG: measures coagulation. First half of graph measure coagulation, then second half measures fibrinolysis.

TEG graphs

Dabigatran Testing

Rivaroxaban Testing

Apixaban Testing

Dabigatran: order TT: If normal, excluded dabigatran OD. ALso if APTT/ dRVVT normal, probably excluded.

Apixaban/Rivaroxaban: If Anti-Xa normal, excluded use. If PT, dRVVT normal, probably excluded.

Basic Test Panel: PT, APTT, TTT. If all normal, likely excludes rivaroxaban/dabigatran. Add on Anti-Xa, if negative, significant TSOAC activity excluded.

4 steps: Discontinue drug, give antidote, give factors, adjuncts.

Idarucizumab: reversal for dabigatran reversal. Reversed lab abnormality. NJEM – 11 hours for cessation of bleeding after given antidote. No control. 25% had ‘serious SE’ including thrombosis.

Warfarin: SNTT (Seven, Nine, Ten, Two): order of how fast they are used. So if you give factor 7, theres still 3 others than occur later. FFP: Each unit of FFP contains 2.5%, need 10% to fix INR. Need at least 4 units of FFP. Slower to reverse bleeding compared to PCCs, also concern for fluid overload, concern for TROLLI.

KCentra: 4 factor PCC: On warfarin, give dosage compared to INR. 1.5-3.9: 25 units/kg, INR 4-6: 35 units/kg, INR >6: 50 units/kg. Newer studies showing lower dose coming out. Fixed dose PCCs – Give 1500 units (3 vials) for almost every patient. Recent studies showing success with fixed dose and saving almost $1000/pt. Consider 2000 units (1 extra vial) for patients > 100kg or INR > 7 (EM PharmD, 2017)

Dabigatran: UMEM gives FEIBA(4 factor PCC with activated 7) 50 units/kg (max 5000). Best data so far (before antidote)

Apixaban/Rivaroxaban: give KCentra 50 units/kg (max 5000), do not repeat.

Activated charcoal: consider giving if just took the medication.

Vitamin K: only give if patient on warfarin.

RRT: Renal replacement therapy: only dialysis medication is dabigatran. Dialysis catheter usually not that big of a deal for bleeding – discuss with nephrology.

References

Reversing the “Bleeder Drugs” in a Hemorrhaging Patient, Brian Hayes, The Crashing Patient Conference 2015.

234. Anticoagulants, Antiplatelet Agents, and Fibrinolytics

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