TEG: measures coagulation. First half of graph measure coagulation, then second half measures fibrinolysis.
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.
Reversing the “Bleeder Drugs” in a Hemorrhaging Patient, Brian Hayes, The Crashing Patient Conference 2015.
Activation of blood coagulation system. Fibrin consumption, leading to thrombosis of small and medium vessels. Eventually leading to organ dysfunction. Fibrin production leads to microthombin, red cell lysis, and diffuse bleeding due to no more clotting factor. Bleeding type usually with OB and leukemic patients. Organ failure with infection and sepsis. Massive bleeding with major surgery and OB procedures. DIC never primary process, likely ARDS. Clinically look for it when bleeding from atypical sites.
Labs: thrombocytopenia (<100), elevated PTT/INR, low fibrinogen (<100), and elevated d-dimer.
Tx: Treat underlying disease. When bleeding, target blood component therapy. If active bleeding and platelets <50, give platelets. If hgb < 7. If INR > 1.6, give FFP. If fibrinogen < 100, give cryoprecipitate. Don’t give PCCs. Only give TXA in recent surgery or acute leukemia. (USC Rounds, 10/12/17).