Guidelines for the Management of Warfarin Reversal For

Guideline for the Treatment of Anticoagulant-Associated Intracerebral Haemorrhage(ICH)
Target “Door to Needle Time”<90 mins
Immediate Action:

Anticoagulant: confirm the anticoagulant, the dose and time last taken
Urgent CT Brain: anypatient on an anticoagulant presenting with headache, new confusion, transient focal neurological symptoms or other clinical suspicion order an immediate CT
Urgent Blood Tests Required:

Vitamin K Antagonist: Check INRon point–of–care-testing (POCT) device and record result in patient’s medical notes. An urgent Coagulation Screen must be taken simultaneously to audit the result of the POCT device as a POCT INR >4.0 may not be accurate (POCT should not be used if patient has antiphospholipid syndrome).If a “C” is recorded beside the POCT INR result, a blood gas to check the HCT should be carried out - a low HCT may affect an INR result
Direct Oral Anticoagulant: Renal Profile, FBC
Type and Screen
Immediate Treatment when ICH Confirmed:

For Vitamin K Antagonist e.g. Warfarin:
Stop Vitamin K Antagonist
Give:

Vitamin K 10mg IV(Phytomenadione - available in ED Drug Press/Pharmacy)
Prothrombin Complex Concentrate (PCC) - Octaplex® (available inED Blood Fridge/Blood Transfusion Lab)

Patient’s weight and current INR are required to calculate dosage of PCC:
Current INR / PCC Dose (Octaplex®)
INR 1.5 – 3.9 / 25 International Units (IU) /kg
INR 4.0 – 6.0 / 35 International Units (IU) / kg
INR > 6.0 / 50 International Units (IU) / kg
Each vial contains 500International Units(IU) or1000 International Units (IU); round dose up to nearest 500 International Units(IU) - Single dose of PCC should not exceed 3000 International Units (IU)
Administration Rate for PCC ICH patients:
1ml/min (1ml/min= 60mls/hr for syringe driver) for 5 mins then increase to 10ml/min (10ml/min = 600ml/hr for syringe driver) for the remaining volume
Recheck INR: Immediately post administration and repeat every 4-6 hours until target INR has been achieved. The effect of PCC persists for approx. 6-8 hrs and the onset action of Vitamin K occurs approximately 1-3 hours after IV administration. If a further dose of PCC is required it must be discussed with Haematology Registrar/Consultant / For Direct Oral Anticoagulants (DOACs)e.g. Apixaban, Rivaroxaban, Edoxaban, Dabigatran:
Note - POCT INR is not required for patients on DOACs. The
INR should not be used as a measurement of anticoagulation. Vitamin K (Phytomenadione) does not reverse DOACs
Apixaban, Rivaroxaban, Edoxaban:
Give:

Prothrombin Complex Concentrate (PCC) - Octaplex®

50 International Units(IU)/kg(available in ED Blood Fridge / Blood Transfusion Lab. Each vial of PCC contains 500 International Units (IU) or 1000 International Units (IU); round dose up to nearest 500 International Units (IU) - Single dose of PCC should not exceed 3000 International Units (IU)
Administration Rate for PCC ICH patients: 1ml/min for 5 mins then increase to 10ml/min (10ml/min = 600ml/hr) for the remaining volume

Tranexamic Acid (available in ED Drug Press/ Pharmacy) 1g every 6-8 hrs by slow IV injection (max.rate 100mg/min) - dose reduction required for renal impairment-information available on MaterNet Pharmacy section or click on link

Dabigatran:
Give:

Idarucizumab 5g (Praxbind®) IV (available in ED Resus Fridge/Pharmacy)
Tranexamic Acid (available in ED Drug Press / Pharmacy)

1g every 6-8 hrs by slow IV injection (max.rate 100mg/min) - dose reduction required for renal impairment- information available on MaterNet Pharmacy section or click on link
For Low Molecular Weight Heparin (LMWH): Stop LMWH and give Protamine Sulphate (available in
ED Drug Press/Pharmacy) information available on MaterNet Pharmacy section or click on link
Important Points:
Medical/Stroke Registrar to contact Haematology Team via switchboard “0” -toinform them of the treatment administered and to discuss if furtherinvestigations/treatment is required. Further laboratory test may be required for specific DOAC assays.
Replace stock of PCC -aNurse must contact the Blood Transfusion Lab and provide them with details of the patient who received the PCC, order replacement stock and send Porter to the lab asap to collect it (Ext 2437/2649 / Bleep 2437)
Replace stock of Idarucizumab - a Nurse must contact pharmacy, provide them with details of the patient who received the Idarucizumab and order replacement stock asap (ext 2259, ) / out of hours contact the Site Nurse Manager
PCC -Information on reconstitution/administration will be available with the product in the ED blood fridge. Affix the patient’s addressograph label on the Traceability Label of each vial of PCC administered and place label in the Traceability Box. Record the prescription and administration of PCC in the Blood/Blood Product Chart.
Vitamin K (Phytomenadione), Tranexamic Acid, Idarucizumab, Protamine Sulphate – must be prescribed in patients Drug Chart
For further information refer toManagement of Warfarin Reversal Guidelinesand Direct Oral Anticoagulants (DOAC) Reversal Guidelinesavailable on MaterNet
Adapted from ‘SRFT protocol for treatment of anticoagulant-associated ICH’ created by Adrian Parry-Jones, Consultant Neurologist (2015)