DEVELOPMENT SITE ONLY
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
PREVENTION
High risk patients
Co-morbidity
- Affecting clotting factor synthesis, vitamin K availability or warfarin metabolism
- cardiac failure
- gastrocolic fistula
- liver disease
- malnutrition
- cholestasis
- abrupt weight reduction
- diarrhoea
- renal impairment
- thyrotoxicosis
- fever
- malignancy
- aged >75 yr
Medications
- Many. Check interactions in the BNF Appendix 1. Use an alternative agent if possible
- most antimicrobials
- concurrent anti-platelet, NSAID, SSRI or SNRI
- Over dosage (accidental or deliberate)
Referral
- Refer patients to the local anticoagulation team for regular monitoring and dosing during inpatient stay and post-discharge
MANAGEMENT
Prosthetic heart valves
- Reversal of anticoagulation may increase the risk of valve thrombosis
- in non-life, limb or sight threatening situations, discuss management with cardiothoracic unit and haematologist
Management of warfarin
- Management of over-anticoagulation depends on the INR, severity of bleeding and underlying thrombotic risk
- Major haemorrhage
- life, limb or sight threatening bleeding including high suspicion pre-imaging
- intra-cerebral bleed
- bleed with haemodynamic instability
- major trauma
- intraocular bleed (excluding subconjunctival)
- muscle bleed resulting in compartment syndrome
- pericardial bleed
- Minor haemorrhage and INR raised
- High INR without bleeding
- Include patients with a prosthetic/metallic heart valve
- If high clinical suspicion of major bleed, do not wait for INR result or imaging
- If required, activate massive haemorrhage pathway (MHP)
Obtain venous access
- Take blood for FBC, INR, APTT, Fibrinogen, U&E, LFT, G&S/crossmatching
STOP warfarin and reverse anticoagulation
- Immediate vitamin K (phytomenadione) 5 mg slow IV AND
- Octaplex® (prothrombin complex concentrate PCC)
- contact blood bank with patient's weight for direct PCC access request
No Prosthetic Heart valves fitted
- Reduce dose or temporarily discontinue warfarin
- Administer IV vitamin K (phytomenadione) 1-3 mg slow IV
- Oral bleeding - consider tranexamic acid mouthwash
- Epistaxis - consider cautery or nasal packing
Prosthetic heart valve(s) fitted
- Reversal of anticoagulation may increase the risk of valve thrombosis
- discuss management with cardiothoracic unit and haematologist
INR >8 and no Prosthetic Heart valves fitted
- Stop warfarin
- Give 2 mg oral vitamin K (phytomenadione)
- Repeat INR in 24 hr
- Restart warfarin at lower dose once INR <5.0 and monitor INR until stable
Prosthetic heart valve(s) fitted
- Reversal of anticoagulation may increase the risk of valve thrombosis
- discuss management with cardiothoracic unit and haematologist
- Consider high risk of bleeding especially if:
- aged >70, hypertension, diabetes, renal failure, previous CVA, previous GI bleed, liver disease
INR 5.0-8.0, high risk of bleeding and no Prosthetic Heart valves fitted
- Stop warfarin
- Give 2 mg oral vitamin K (phytomenadione)
- Repeat INR in 24 hr
- Restart warfarin at lower dose once INR <5.0 and monitor INR until stable
INR 5.0=8.0, low risk of bleeding and no Prosthetic Heart valves
- Withhold 1-2 doses of warfarin
- Reduce maintenance dose
Prosthetic heart valve(s) fitted
- Reversal of anticoagulation may increase the risk of valve thrombosis
- discuss management with cardiothoracic unit and haematologist
Other management
If there is a high clinical suspicion of ICH, do not wait for INR result or imaging
- Intracranial bleeding in association with warfarin therapy is a medical emergency
- urgent assessment, imaging and treatment
- seek neurosurgery advice
- Consider local, endoscopic, interventional radiological and surgical measures early for all bleeds
- Investigate cause for elevated INR
RESTARTING WARFARIN AFTER A MAJOR BLEED
- Report any patient with anticoagulation associated bleeding to hospital incident system
- Review the need for anticoagulation; confirm duration, intensity and concurrent medication
- Assess bleeding risk factors and address any potential cause for re-bleeding
- Seek specialist input from relevant team e.g. neurosurgery, gastroenterology
- Discuss with the haemostasis team before re-starting anticoagulation
- Assess suitability of alternative anticoagulants
- All cases will be reviewed by the local anticoagulation team