vitamin-k-1 and Emergencies

To describe the pharmacologic agents and strategies used for urgent reversal of warfarin and the target-specific oral anticoagulants dabigatran, rivaroxaban, and apixaban.. To reverse the anticoagulant effects of warfarin in patients who are bleeding or need surgery, exogenous vitamin K (phytonadione) may be used in combination with another, shorter-acting intervention, such as fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), recombinant factor VIIa, or activated PCC (aPCC). Three-factor PCC contains factors II, IX, and X in an inactivated form, and four-factor PCC also includes factor VII in an inactivated form. No four-factor PCC products are available in the United States, but aPCC, which contains the same four factors with factor VII provided in an activated form, is available. The intervention depends on the International Normalized Ratio, presence of bleeding, and need for and timing of surgery. Research suggests that clotting factor concentrates are more effective than FFP alone for warfarin reversal. These products also may be useful for reversing the effects of target-specific oral anticoagulants, but limited efficacy and safety data are available to support their use. The risks and benefits associated with these products need to be weighed before their use for reversal of dabigatran, rivaroxaban, or apixaban. Additional clinical data are needed to clearly define the role of concentrated clotting factor products in reversal and to determine the optimal clotting factor concentrate product and dose for urgent reversal of oral anticoagulation.. Phytonadione and clotting factor concentrates appear to have a role for reversal of warfarin, and limited evidence suggests that clotting factor concentrates could have a role in reversal of target-specific oral anticoagulants in an emergency situation.

Topics: Administration, Oral; Anticoagulants; Antifibrinolytic Agents; Antithrombins; Benzimidazoles; beta-Alanine; Blood Coagulation Factors; Blood Loss, Surgical; Dabigatran; Drug Therapy, Combination; Emergencies; Hemorrhage; Humans; International Normalized Ratio; Morpholines; Plasma; Pyrazoles; Pyridones; Rivaroxaban; Surgical Procedures, Operative; Thiophenes; Thromboembolism; Treatment Outcome; Vitamin K 1; Warfarin

To describe a process for prompt evaluation and management- including reversal of the effects of warfarin and target-specific oral anticoagulants-of patients with or at high risk for bleeding during oral anticoagulant therapy or when such therapy is interrupted for an urgent invasive procedure or surgery.. The use of pharmacologic interventions for anticoagulant reversal may depend on the measured level of anticoagulation, time since the last anticoagulant dose, target level of coagulation, reliability of laboratory tests of coagulation, severity of or risk for bleeding, the agents' mechanism of action and pharmacokinetics, and pharmacodynamics of the reversal agent. The patient's age, weight, renal function, comorbid conditions, and other drug therapy, as well as the risk for thromboembolism and other adverse effects of the reversal therapies, also enter into therapeutic decisions. Hemodialysis may be used to remove the direct thrombin (factor IIa) inhibitor dabigatran and reverse its anticoagulant effects. Limited experience with clotting factor concentrates suggests that activated prothrombin complex concentrate may be useful for reversing the anticoagulant effects of dabigatran. The activity of oral factor Xa inhibitors (i.e., rivaroxaban and apixaban) is higher up the common pathway of the coagulation cascade and thus may be easier to reverse than that of direct thrombin inhibitors. Additional clinical experience is needed to identify the optimal reversal agents, dosage, and impact on thrombosis or bleeding outcomes for both classes of agents.. A comprehensive plan individualized to each agent should be developed to promptly reverse the effects of oral anticoagulants and optimize outcomes in patients with bleeding or an urgent need for surgery.

Topics: Administration, Oral; Adult; Anticoagulants; Antifibrinolytic Agents; Blood Coagulation Factors; Emergencies; Hemorrhage; Humans; Renal Dialysis; Risk Assessment; Risk Factors; Surgical Procedures, Operative; Treatment Outcome; Vitamin K 1; Warfarin

Warfarin anti-coagulation can cause significant delay in acute surgical admissions. We reviewed fracture neck of femur patients operated over a period of 4 years in our unit. There was an average delay to surgery of 4.36 days in patients on warfarin as against an average delay of 1.78 days in patients not on warfarin (p < 0.001). The review was followed up with a questionnaire-based survey of consultant haematologists, and a general agreement towards a protocol-based use of vitamin K(1) was noted. The reasons for limited use of vitamin K(1) include the lack of studies and guidelines specifically addressing the pre-operative emergency admissions. We highlight a practical problem shared across different specialities and identify the areas for future studies.

Topics: Aged; Aged, 80 and over; Anticoagulants; Emergencies; Epidemiologic Methods; Female; Femoral Neck Fractures; Humans; Male; Middle Aged; Preoperative Care; Time Factors; United Kingdom; Vitamin K 1; Warfarin

Patients on oral anticoagulants who present to the emergency department following trauma pose a special problem. Careful attention must be given to exclude any sites of overt or occult bleeding, particularly in the CNS, where there may be no external evidence of injury. A PT or thrombotest should be obtained as minimum laboratory workup in all cases. In specific situations, emergency reversal of anticoagulation must be undertaken.

Topics: Anticoagulants; Cardiovascular Diseases; Emergencies; Hemorrhage; Humans; Risk; Vitamin K 1; Wounds and Injuries

In a patient taking oral anticoagulants, the complaint of pharyngeal pain, a change in the voice, dysphagia, respiratory difficulty, or a neck mass should prompt a thorough investigation to rule out hemorrhage into the upper airway. This case report describes an anticoagulated patient who experienced precipitous hemorrhagic upper airway obstruction. She was successfully treated with tracheostomy, plasma infusion, and parenteral vitamin K1.

Topics: Airway Obstruction; Emergencies; Female; Hematoma; Hemorrhage; Humans; Middle Aged; Respiratory Tract Diseases; Thrombophlebitis; Tracheotomy; Vitamin K 1; Warfarin

Topics: Administration, Intravenous; Antifibrinolytic Agents; Coumarins; Dicumarol; Emergencies; Emulsions; Naphthoquinones; Prothrombin; Vitamin K; Vitamin K 1