warfarin and Emergencies

Topics: Anticoagulants; Aspirin; Benzimidazoles; Clopidogrel; Dabigatran; Emergencies; Enoxaparin; Fondaparinux; Heparin; Humans; Morpholines; Platelet Aggregation Inhibitors; Platelet Transfusion; Polysaccharides; Pyrazoles; Pyridines; Pyridones; Rivaroxaban; Surgical Procedures, Operative; Thiophenes; Ticlopidine; Warfarin

Dabigatran and rivaroxaban are novel anticoagulants that have been approved for the prevention of thromboembolic events in atrial fibrillation. These medications are attractive to both patients and clinicians, as, unlike warfarin, they do not require laboratory monitoring or dietary restrictions. However, they carry bleeding risks similar to that of warfarin and are without a reliable reversal agent.. The objectives of this article are to 1) summarize the pivotal trials leading to the U.S. Food and Drug Administration approvals of dabigatran (Pradaxa; Boehringer Ingelheim, Ridgefield, CT) and rivaroxaban (Xarelto; Janssen Pharmaceuticals, Inc., Titusville, NJ); 2) present the limited data available regarding the management of bleeding patients on these agents; and 3) provide suggestions to guide emergency providers given the limited data.. Dabigatran and rivaroxaban were approved based on large, non-inferiority trials comparing the new agents to warfarin with stroke or systemic embolism as the primary outcome. Traditional coagulation studies cannot be used to determine the degree of anti-coagulation produced by these agents. Fresh frozen plasma is unlikely to be effective in patients on these drugs who are acutely bleeding. Prothrombin complex concentrate can be considered in patients on rivaroxaban. Dabigatran is renally cleared, so dabigatran could be removed by hemodialysis. Theoretically, DDAVP (Sanofi-Aventis U.S. LLC, Bridgewater, NJ), aminocaproic acid, tranexamic acid, or recombinant activated factor VII could also be used in an attempt to control bleeding.. There is a need for assays for the degree of anticoagulation produced by drugs such as dabigatran and rivaroxaban. Additionally, studies are needed to evaluate reversal agents that could be effective in the setting of acute bleeding.

Topics: Anticoagulants; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Dabigatran; Drug Approval; Emergencies; Hemorrhage; Humans; Morpholines; Rivaroxaban; Stroke; Thiophenes; United States; United States Food and Drug Administration; Warfarin

Topics: Anticoagulants; Aspirin; Emergencies; Heparin; Humans; Plasminogen Activators; Platelet Aggregation Inhibitors; Pulmonary Embolism; Thrombolytic Therapy; Urokinase-Type Plasminogen Activator; Warfarin

Sublingual hematoma is a rare but potentially fatal complication of oral warfarin sodium. Less than ten cases are reported in the English-language literature with only two of these appearing in the otolaryngologic literature. Spontaneous bleeding into the sublingual and submaxillary spaces creates a "pseudo-Ludwig's" phenomenon with elevation of the tongue and floor of mouth and subsequent airway compromise. Two new cases, along with a review of the literature are presented. Management is directed at prompt control of the airway and reversal of the coagulopathy. Sore throat is a uniform, early complaint that should be taken seriously in any patient receiving oral anticoagulation therapy.

Topics: Aged; Airway Obstruction; Emergencies; Female; Hematoma; Humans; Middle Aged; Oral Hemorrhage; Tongue Diseases; Warfarin

This study compares the safety and efficacy of a fixed dose of 4-factor prothrombin complex concentrate (4FPCC) to the FDA-approved variable dosing for reversal of warfarin-induced anticoagulation.. This was a single-center, prospective, open-label, randomized controlled trial with subjects randomized to 4FPCC at a fixed dose of 1500 IU or the FDA-approved variable dosing regimen. The primary efficacy outcome (reversal success) was defined as a post-intervention international normalized ratio (INR) of less than or equal to 1.5. Given that 4FPCC is the standard of care for reversal of warfarin-induced anticoagulation an active-controlled approach was employed with the two dosing regimens compared based on efficacy, cost, and safety outcomes.. 71 subjects (34 in the fixed dose group and 37 in the variable dose group) completed the study. There were no significant differences in age, gender, weight, initial INR, or indication for 4FPCC administration between the two treatment groups. Reversal success in the fixed-dose group was 61.8%, while in the variable dose group reversal success was 89.2%. Reversal success in the fixed-dose group was significantly lower than the rate of reversal success in the variable dose group (27.4% lower, p = 0.011).. The results of this study provide evidence that fixed dosing results in lower reversal success rates as compared to variable dosing of 4FPCC for warfarin-induced anticoagulation.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation Factors; Emergencies; Female; Gastrointestinal Hemorrhage; Hemorrhage; Humans; International Normalized Ratio; Intracranial Hemorrhages; Male; Middle Aged; Severity of Illness Index; Treatment Outcome; Warfarin

To explore the efficiency and safety of bivalirudin in patients undergoing emergency percutaneous coronary intervention via radial access.. Bivalirudin reduces bleeding risks over heparin in patients undergoing PCI. However, bleeding advantages of bivalirudin in patients undergoing transradial intervention is uncertain.. In the BRIGHT trial, 1,723 patients underwent emergency PCI via radial access, with 576 patients in the bivalirudin arm, 576 in the heparin arm and 571 in the heparin plus tirofiban arm. The primary outcome was 30-day net adverse clinical event (NACE), defined as a composite of major cardiac and cerebral events or any bleeding.. 30-day NACE occurred in 5.7% with bivalirudin, 7.8% with heparin alone (vs. bivalirudin, P = 0.159), and 10.3% with heparin plus tifofiban (vs. bivalirudin, P = 0.004). The 30-day bleeding rate was 0.9% for bivalirudin, 2.3% for heparin (vs. bivalirudin, P = 0.057), and 5.8% for heparin plus tirofiban (vs. bivalirudin, P < 0.001). Major cardiac and cerebral events (4.9 vs. 5.7 vs. 4.6%, P = 0.899), stent thrombosis (0.5 vs. 0.5 vs. 0.7%, P = 0.899) and acquired thrombocytopenia (0.2 vs. 0.5 vs. 0.9%, P = 0.257) at 30 days were similar among three arms. The interaction test for PCI access and randomized treatment showed no significance on all bleeding (P > 0.05).. The bleeding benefit of bivalirudin was independent of artery access. Bivalirudin lead to statistical reduction on bleeding risks in comparison to heparin plus tirofiban, and only small numerical difference in comparison to heparin, with comparable risks of ischemic events and stent thrombosis in patients with acute myocardial infarction (AMI) undergoing emergency transradial PCI. © 2016 Wiley Periodicals, Inc.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Antithrombins; Cardiac Catheterization; China; Emergencies; Female; Hemorrhage; Hirudins; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Non-ST Elevated Myocardial Infarction; Peptide Fragments; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Radial Artery; Recombinant Proteins; Risk Assessment; Risk Factors; ST Elevation Myocardial Infarction; Time Factors; Tirofiban; Treatment Outcome; Tyrosine; Warfarin; Young Adult

Haemorrhage, including intracranial bleeding, is a common, potentially lethal complication of warfarin therapy and rapid and complete reversal of anticoagulation may be life-saving. Fresh frozen plasma (FFP) and vitamin K are most frequently administered. Because of the variable content of vitamin K-dependent clotting factors in FFP, and the effects of dilution, the efficacy of this approach is open to doubt. We have therefore compared the effects of FFP and clotting factor concentrates on the INRs and clotting factor levels of orally anticoagulated subjects requiring rapid correction of their haemostatic defect. In many, the pre-treatment INR was considered to be dangerously above the target therapeutic range. In the 12 patients given FFP, the INR did not completely correct (range 1.6-3.8, mean 2.3) indicating an ongoing anticoagulated state in all. In contrast, the INR in 29 subjects given clotting factor concentrates was completely corrected in 28 (range 0.9-3.8, mean 1.3). Following treatment, marked differences were observed in clotting factor IX levels between the two groups. The median factor IX level was 19 u/dl (range 10-63) following FFP infusion and 68.5 u/dl (range 31-111) following concentrate. In FFP treated patients, poorer responses were also observed for each of the other vitamin K-dependent clotting factors but these were less marked than for factor IX, which was present in low concentrations in some batches of FFP. Thus, haemostatically effective levels of factor IX cannot be achieved, in most instances, by the conventional use of FFP in patients requiring reversal of their anticoagulant therapy. Clotting factor concentrates are the only effective option where complete and immediate correction of the coagulation defect is indicated in orally anticoagulated patients with life or limb-threatening haemorrhage.

Topics: Administration, Oral; Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation Factors; Emergencies; Factor IX; Factor VII; Factor X; Female; Hemorrhage; Humans; Male; Middle Aged; Plasma; Prothrombin; Regression Analysis; Warfarin

Prothrombin Complex Concentrates (PCC) are prescribed for emergent warfarin reversal (EWR). The comparative effectiveness and safety among PCC products are not fully understood.. Patients in an academic level one trauma center who received PCC3 or PCC4 for EWR were identified. Patient characteristics, PCC dose and time of dose, pre- and post-INR and time of measurement, fresh frozen plasma and vitamin K doses, and patient outcomes were collected. Patients whose pre-PCC International Normalized Ratio (INR) was > 6 h before PCC dose or the pre-post PCC INR was > 12 h were excluded. The primary outcome was achieving an INR ≤ 1.5 post PCC. Secondary outcomes were the change in INR over time, post PCC INR, thromboembolic events (TE), and death during hospital stay. Logistic regression modelled the primary outcome with and without a propensity score adjustment accounting for age, sex, actual body weight, dose, initial INR value, and time between INR measurements. Data are reported as median (IQR) or n (%) with p < 0.05 considered significant.. Eighty patients were included (PCC3 = 57, PCC4 = 23). More PCC4 patients achieved goal INR (87.0% vs. 31.6%, odds ratio (OR) = 14.4, 95% CI: 3.80-54.93, p < 0.001). This result remained true after adjusting for possible confounders (AOR = 10.7, 95% CI: 2.17-51.24, p < 0.001). The post-PCC INR was lower in the PCC4 group (1.3 (1.3-1.5) vs. 1.7 (1.5-2.0)). The INR change was greater for PCC4 (2.3 (1.3-3.3) vs. 1.1 (0.6-2.0), p = 0.003). Death during hospital stay (p = 0.52) and TE (p = 1.00) were not significantly different.. PCC4 was associated with a higher achievement of goal INR than PCC3. This relationship was observed in the unadjusted and propensity score adjusted results.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation Factors; Body Weight; Emergencies; Female; Humans; International Normalized Ratio; Male; Middle Aged; Plasma; Propensity Score; Retrospective Studies; Time Factors; Trauma Centers; Vitamin K; Warfarin

Reversal of warfarin-induced coagulopathy after traumatic injury may be done exclusively with prothrombin complex concentrates (PCCs). No direct comparisons between different PCC regimens exist to guide clinical decision-making. Our institution has used 2 distinct PCC strategies for warfarin reversal; a 3-Factor PCC (Profilnine) combined with activated Factor VII (3F-PCC+rVIIa), and a 4-Factor PCC (Kcentra) given without additional factor supplementation.. Retrospective review of all PCC administrations to trauma patients with acute bleeding who were taking warfarin before injury. Primary endpoints were international normalized ratio (INR) reduction, in-hospital mortality, and diagnosis of deep venous thrombosis (DVT).. Eighty-seven patients were identified from 2011 to 2015. Fifty-three were treated with 3F-PCC+rVIIa and 34 with 4F-PCC. Patient demographics, injury severity, and presenting laboratory data were similar. The 3F-PCC+rVIIa produced a lower median (IQR) INR postreversal compared with 4F-PCC (.75 (.69, 1.00) vs 1.28 (1.13, 1.36), P<.001). Both regimens were able to obtain an INR lower than 1.5 immediately after administration (3F+rVIIA 93.9% vs 4F 97.1%, P =.51). In the 4F-PCC group, there was a significant decrease in the incidence of DVT (2.9% vs 22.6%), P < .01), and a nonsignificant reduction in mortality (2.9% vs 17.0%, P = .08).. Use of 4F-PCC for warfarin reversal after traumatic hemorrhage is associated with a less severe decrease in INR, a significant reduction in DVT rates and a trend toward reduced mortality when compared with similar patients treated with 3F-PCC+rVIIa.

Topics: Aged; Aged, 80 and over; Blood Coagulation Factors; Chi-Square Distribution; Cohort Studies; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Combinations; Emergencies; Factor IX; Factor VII; Factor X; Female; Follow-Up Studies; Hemorrhage; Humans; International Normalized Ratio; Male; Middle Aged; Prothrombin; Retrospective Studies; Risk Assessment; Severity of Illness Index; Statistics, Nonparametric; Treatment Outcome; Vitamin K; Warfarin; Wounds and Injuries

Previous trials investigating usage of four-factor prothrombin complex concentrate (4F-PCC) excluded patients with various thrombotic risk factors. The objective of this study was to evaluate the safety and effectiveness of 4F-PCC in a real-world setting based on an institutional protocol that does not have strict exclusion criteria.. This was a retrospective study of adult patients who received 4F-PCC. The primary outcome was a confirmed thromboembolism within 14 days after 4F-PCC administration. Secondary outcomes included international normalized ratio (INR) correction to <1.5 at first draw and incidence of INR rebound for patients undergoing reversal of warfarin and hemostatic effectiveness for patients experiencing a bleed.. Ninety-three patients received 4F-PCC. Sixty-three (67.7%) were reversed for bleeding and 30 (32.3%) for surgery. Eleven patients (11.8%) developed a thromboembolism within 14 days. The median (interquartile range) time to event was 5 (2-7) days. Significant risk factors were heparin-induced thrombocytopenia (P= .01) and major surgery within 14 days (P= .02), as well as the presence of >6 thrombotic risk factors (P= .01). For patients post-warfarin reversal, 45/63 (71.4%) achieved INR correction at first draw, 55/63 (87.3%) achieved INR correction within 24 hours, and 14/55 (25.5%) experienced INR rebound. Of these 14 patients, 8 (57.1%) did not receive concomitant vitamin K.. 4F-PCC was associated with a notable thromboembolic risk. All patient-specific risk factors should be considered prior to administration. 4F-PCC remains a useful agent for warfarin reversal. Lack of concomitant vitamin K may contribute to INR rebound.

Topics: Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Blood Coagulation Factors; Cardiac Surgical Procedures; Dabigatran; Emergencies; Female; Gastrointestinal Hemorrhage; Heart Transplantation; Hemorrhage; Hemostatics; Heparin; Humans; Incidence; International Normalized Ratio; Intracranial Hemorrhages; Laparotomy; Male; Middle Aged; Preoperative Care; Pyrazoles; Pyridones; Retrospective Studies; Risk Factors; Rivaroxaban; Surgical Procedures, Operative; Thrombocytopenia; Thromboembolism; Vitamin K; Warfarin

The aim of this study is to investigate postoperative complications, mortality rates, and to determine the factors affecting mortality on the patients receiving warfarin therapy preoperatively, as well as comparing the results obtained from emergency and elective surgeries. Surgical outcomes of 61 patients on long-term oral anticoagulation with warfarin who underwent surgery in our center were retrospectively reviewed over an 8-year period. Thirty-three (54.1%) patients were female, with a mean age of 53 years. Mitral valve replacement (62.3%) was the most frequent indication for chronic anticoagulation therapy. Twelve out of 61 (19.2%) patients underwent emergency surgery; 59 (96.7%) operations were classified as major surgery. We did not observe any thromboembolic events on patients receiving our bridging therapy protocol. Cardiopulmonary dysfunction (CPD; 19.7%) and hemorrhage (16.4%) were the most encountered postoperative complications. Presence of CPD, bleeding, endocarditis, and mortality were statistically significant for emergency surgeries when compared with the results obtained from elective surgeries. There were 5 (8.2%) deaths observed during follow-up. It was found that advanced age, prolonged duration of operations, and presence of CPD had a statistically significant effect on mortality (P < 0.05). The patients receiving oral anticoagulant had high postoperative complication and mortality rates. This case was more evident in emergency surgeries. It is recommendable that as mortality is more apparent in the patients who undergo emergency surgeries-being older, having long duration of operations as well as CPD. Therefore during the postoperative follow-up process, the patients should be closely monitored.

Topics: Anticoagulants; Emergencies; Female; Humans; Middle Aged; Mitral Valve; Postoperative Complications; Preoperative Period; Retrospective Studies; Warfarin

There are two upper-extremity deep venous thrombosis (UEDVT) cases after whole blood donation reported in the English medical literature. Three additional UEDVT cases after whole blood donation were reported to our blood center within a 13-month period.. A case study was done for each case in collaboration with a clinical physician. A description of the donation event, donor demographics, risk factors for thrombosis, treatment, and outcome were described.. A 33-year-old woman and two 17-year-old, first-time-donating men presented with arm pain, swelling, and bruising within hours to 3 days after donation. Two had distal UEDVTs in the basilic or brachial veins, and one had a proximal UEDVT in the subclavian and axillary veins extending into the basilic vein. One donor (woman) had known risk factors for DVT and the other two did not. Anticoagulant therapy was initiated on all patients and was continued for 3, 4, and 9 months. Two donors with the distal UEDVTs recovered completely while the donor with the proximal UEDVT was treated with anticoagulation for 9 months and continued to have a slight residual, nonobstructive thrombosis. The donor was switched to low-dose aspirin prevention. The two donors reported in the literature had complete resolution of thrombosis.. Four of five donors recovered completely after anticoagulation treatment for UEDVT, including two of three donors in this study. A review of all cases in the medical literature, including 20 recent Australian cases described in an abstract, provides a more complete description of this adverse donation injury.

Topics: Adolescent; Adult; Androstenes; Blood Donors; Contraceptives, Oral, Hormonal; Drug Substitution; Emergencies; Enoxaparin; Ethinyl Estradiol; Female; Humans; Male; Phlebotomy; Promoter Regions, Genetic; Prothrombin; Thrombophilia; Upper Extremity Deep Vein Thrombosis; Warfarin

Mitral valve prolapse is not commonly on the list of differential diagnosis when a patient presents in the emergency department (ED) in severe distress, presenting with non-specific features such as abdominal pain, tachycardia and dyspnea. A healthy 55-year-old man without significant past medical history arrived in the ED with a unique presentation of a primary mitral valve prolapse with an atrial septal defect uncommon in cardiology literature. Early recognition of mitral valve prolapse in high-risk patients for severe mitral regurgitation or patients with underlying cardiovascular abnormalities such as an atrial septal defect is crucial to prevent morbid outcomes such as sudden cardiac death.

Topics: Abdominal Pain; Anticoagulants; Anxiety; Cardiotonic Agents; Continuous Positive Airway Pressure; Digoxin; Dopamine; Dyspnea; Electrocardiography; Emergencies; Heart Septal Defects, Atrial; Heart Valve Prosthesis Implantation; Humans; Male; Metoprolol; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Prolapse; Treatment Outcome; Warfarin

Optimal dosing of prothrombin complex concentrate (PCC) has yet to be defined and varies widely due to concerns of efficacy and thrombosis. We hypothesized a dose of 15 IU/kg actual body weight of a three-factor PCC would effectively correct coagulopathy in acute care surgery patients. Retrospective review of 41 acute care surgery patients who received 15 IU/kg (± 10%) actual body weight PCC for correction of coagulopathy. Demographics, laboratory results, PCC dose, blood and plasma transfusions, and thrombotic complications were analyzed. We performed subset analyses of trauma patients and those taking warfarin. Mean age was 69 years (18-94 years). Thirty (73%) trauma patients, 8 (20%) emergency surgery patients, 2 (5%) burns, and 1 (2%) nontrauma neurosurgical patient were included. Mean PCC dose was 1305.4 IU (14.2 IU/kg actual body weight). Mean change in INR was 2.52 to 1.42 (p 0.00004). Successful correction (INR <1.5) was seen in 78 per cent. Treatment failures had a higher initial INR (4.3 vs 2.03, p 0.01). Mean plasma transfusion was 1.46 units. Mean blood transfusion was 1.61 units. Patients taking prehospital warfarin (n = 29, 71%) had higher initial INR (2.78 vs 1.92, p 0.05) and received more units of plasma (1.93 vs 0.33, p 0.01) than those not taking warfarin. No statistical differences were seen between trauma and nontrauma patients. One thrombotic event occurred. Administration of low-dose PCC, 15 IU/kg actual body weight, effectively corrects coagulopathy in acute care surgery patients regardless of warfarin use, diagnosis or plasma transfusion.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Blood Coagulation Disorders; Blood Coagulation Factors; Blood Transfusion; Body Weight; Burns; Drug Dosage Calculations; Emergencies; Humans; International Normalized Ratio; Middle Aged; Plasma; Retrospective Studies; Surgical Procedures, Operative; Thrombosis; Vitamin K; Warfarin; Wounds and Injuries; Young Adult

New oral anticoagulants (NOACs) offer an alternative to warfarin for preventing stroke in patients with atrial fibrillation. NOACs are expected to replace warfarin and other vitamin K antagonists for most of their indications in the future. Knowledge of the use of NOACs in the perioperative period is important for optimal care.. Studies that reported on the use of NOACs were identified, focusing on evidence-based guidance relating to the perioperative period. PubMed was searched for relevant articles published between January 2000 and January 2014.. The anticipated expanded clinical use of NOACs such as rivaroxaban (Xarelto™), apixaban (Eliquis™) and dabigatran (Pradaxa™) has the potential to simplify perioperative anticoagulant management because of fewer drug-drug interactions, rapid onset of action, predictable pharmacokinetics and relatively short half-lives. However, coagulation status cannot be monitored by international normalized ratio and no antidotes are currently available. In elective surgery, it is important to discontinue the use of NOACs, with special consideration of renal function as route of elimination. Guidelines for the management of bleeding complications in patients on NOACs are provided, and may be considered for trauma and emergency surgery. Haemodialysis could be considered for bleeding with use of dabigatran. Better options for reversal of the effects of NOACs when bleeding occurs may follow with novel drugs.. Management of NOACs in elective and emergency conditions requires knowledge of time of last intake of drug, current renal function and the planned procedure in order to assess the overall risk of bleeding. Currently no antidote exists to reverse the effects of these drugs.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Biological Availability; Clinical Trials as Topic; Dabigatran; Drug Monitoring; Elective Surgical Procedures; Emergencies; Half-Life; Hemorrhage; Humans; Medication Adherence; Morpholines; Preoperative Care; Pyrazoles; Pyridines; Pyridones; Rivaroxaban; Stroke; Thiazoles; Thiophenes; Time Factors; Warfarin

Endoleak after endovascular aortic aneurysm repair (EVAR) can affect the durability of the repair and lead to continued sac expansion, rupture, and the need for further endovascular or open surgical interventions. The purpose of this study was to determine whether chronic anticoagulation therapy with warfarin is associated with an increased incidence of endoleak and thus increased need for reintervention after EVAR.. We reviewed the records of 401 consecutive patients who underwent EVAR at a single institution from 2003 until 2011. Patients on warfarin were compared with a control group not on warfarin. Primary endpoints included reintervention, defined as rupture, explant, or angiography; death from any cause; and a composite outcome of reintervention or death. The presence of an endoleak at last follow-up, identified by computed tomography or ultrasound scan, and increase of more than 5 mm in aneurysm sac size were secondary endpoints. Cox proportional hazards models were used to estimate the effect of warfarin use on the primary and secondary outcomes, controlling for age, gender, obesity, specific comorbidities, antiplatelet drugs, statin use, and urgency of EVAR.. Three hundred sixty-three patients with a median follow-up period of 29 months had sufficient data for analysis. Warfarin use was not associated with an increased risk of any of the primary endpoints. Controlling for covariates and length of observation via proportional hazards models, the effect of warfarin remained insignificant. It was found, however, on regression analysis, that adverse outcomes were more prevalent after emergency EVAR and in patients deemed unfit for open surgical repair.. Chronic oral anticoagulation does not appear to affect the incidence of endoleak after EVAR, nor does it impact the need for reintervention or degree of sac regression. We feel that warfarin may be safely used in post-EVAR patients. It appears that adverse long-term outcomes are more likely after emergency EVAR and in patients deemed unfit for open surgery.

Topics: Aged; Anticoagulants; Aortic Aneurysm; Aortic Rupture; Aortography; Blood Vessel Prosthesis Implantation; Drug Administration Schedule; Elective Surgical Procedures; Emergencies; Endoleak; Endovascular Procedures; Female; Humans; Incidence; Kaplan-Meier Estimate; Maine; Male; Multivariate Analysis; Predictive Value of Tests; Proportional Hazards Models; Reoperation; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler, Duplex; Warfarin

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

The Joint Commission Venous Thromboembolism (VTE) National Hospital Inpatient Quality Measure VTE-5 outlines four criteria for discharge patient education when starting anticoagulation (usually, warfarin) therapy. The criteria do not specify content regarding patient recognition of potentially dangerous warfarin-related scenarios. A study was conducted to investigate how well patients assess the risks and consequences of potential warfarin-related safety threats.. From an adult population on long-term warfarin, 480 patients were randomly selected for a telephone-based survey. Warfarin-knowledge questions were drawn from a previous survey; warfarin-associated risk scenarios were developed via focus interviews. Expert anticoagulation pharmacists categorized each scenario as urgent, moderately urgent, or not urgent, as did survey participants.. For the 184 patients (38% completion rate), the mean knowledge score was 69% (standard deviation [SD], 0.20). Overall classification accuracy of situational urgency was 59% (95% confidence interval [CI], 57.3%-60.3%). Respondents overestimated non-urgent-severity situations 23% of the time (95% CI, 20.8%-24.7%), while underestimating urgent-severity situations 21% of the time (95% CI, 19.0%-23.9%). A significant percentage of patients failed to recognize the urgency of stroke symptoms (for example, loss of vision), the risk of bleeding after incidental head trauma, or medication mismanagement.. Despite fair factual warfarin knowledge, participants did not appear to recognize well the clinical severity of warfarin-associated scenarios. Warfarin education programs should incorporate patient-centered strategies to teach recognition of high-risk situations that compromise patient safety.

Topics: Aged; Anticoagulants; Emergencies; Female; Health Knowledge, Attitudes, Practice; Hemorrhage; Humans; Male; Patient Safety; Patients; Pharmaceutical Services; Risk Factors; Socioeconomic Factors; Warfarin

Thromboprophylaxis with oral anticoagulants (OACs) is an important but underused element of atrial fibrillation (AF) treatment. Reduction of stroke risk with anticoagulants comes at the price of increased bleeding risk. Patients with AF receiving anticoagulants require heightened attention with transition from one care setting to another. Patients presenting for emergency care of anticoagulant-related bleeding should be triaged for the severity and source of the bleeding using appropriate measures, such as discontinuing the OAC, administering vitamin K, when appropriate, to reverse warfarin-induced bleeding, or administering clotting factors for emergent bleeding. Reversal of OACs in patients admitted to the hospital for surgery can be managed similarly to patients with bleeding, depending on the urgency of the surgical procedure. Patients with AF who are admitted for conditions unrelated to AF should be assessed for adequacy of stroke risk prophylaxis and bleeding risk. Newly diagnosed AF should be treated in nearly all patients with either warfarin or a newer anticoagulant. Patient education is critically important with all anticoagulants. Close adherence to the prescribed regimen, regular international normalized ratio testing for warfarin, and understanding the stroke risk conferred by both AF and aging are goals for all patients receiving OACs. Detailed handoff from the hospitalist to the patient's primary care physician is required for good continuity of care. Monitoring by an anticoagulation clinic is the best arrangement for most patients. The elderly, or particularly frail or debilitated patients who are transferring to long-term care, need a detailed transfer of information between settings, education for the patient and family, and medication reconciliation. Communication and coordination of care among outpatient, emergency, inpatient, and long-term care settings are vital for patients with AF who are receiving anticoagulants to balance stroke prevention and bleeding risk.

Topics: Administration, Oral; Aftercare; Aged; Anticoagulants; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Continuity of Patient Care; Dabigatran; Drug Monitoring; Drug Substitution; Emergencies; Hemorrhage; Humans; Morpholines; Patient Education as Topic; Rivaroxaban; Stroke; Thiophenes; Warfarin

Topics: Anticoagulants; Dose-Response Relationship, Drug; Emergencies; Hemorrhage; Humans; Vitamin K; Warfarin

A 61-year-old man receiving anticoagulant therapy after the aortic valve replacement underwent emergency surgery for acute appendicitis. Although the patient was intubated with difficulty, no immediate complications were evident after extubation. On the evening of the first postoperative day he complained of a sore throat, difficulty in swallowing and dysphonia. The swelling of the tongue with right-side predominance and the swelling of the right neck were observed. The right-sided sublingual hematoma was confirmed by CT. The symptoms improved with steroid administration. The possibility of airway obstruction due to hematoma of the tongue should be considered in patients on anticoagulant therapy.

Topics: Acute Disease; Airway Obstruction; Anticoagulants; Appendicitis; Dexamethasone; Emergencies; Hematoma; Humans; Infusions, Intravenous; Laryngoscopy; Male; Middle Aged; Mouth Floor; Treatment Outcome; Warfarin

Topics: Emergencies; Exanthema; Female; Humans; Leg; Middle Aged; Necrosis; Skin; Venous Thrombosis; Warfarin

Topics: Anticoagulants; Blood Coagulation; Emergencies; Hemorrhage; Humans; Practice Guidelines as Topic; Prothrombin Time; Recombinant Proteins; Warfarin

Topics: Accidental Falls; Acetazolamide; Administration, Oral; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Blindness; Combined Modality Therapy; Decompression, Surgical; Emergencies; Female; Follow-Up Studies; Humans; Infusions, Intravenous; Orbit; Retrobulbar Hemorrhage; Tomography, X-Ray Computed; Visual Acuity; Warfarin; Wounds, Nonpenetrating

The management of warfarin therapy in patients undergoing surgery or other invasive procedures involves a balance between the risk of hemorrhage, and the risk of thrombosis. Risk of hemorrhage and the trombosis depends on the type of procedure and on pre-existing conditions. Procedures with low risk of hemorrhage (dental, dermatologic or ophtalmologic procedures, endoscopy) can be provided with continuing anticoagulant therapy. Surgery with high hemorrhagic risk need stop warfarin and start bridging anticoagulant therapy, such as unfractionated heparin or low molecular weight heparin, prior and after surgery. In patients requiring emergency surgery, vitamin K, prothrombin complex concentrate or fresh frozen plasma can be used to improve coagulation.

Topics: Anticoagulants; Emergencies; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Perioperative Care; Preoperative Care; Risk Factors; Warfarin

A 6-month-old girl with a diagnosis of double-outlet right ventricle and pulmonary stenosis had a left modified Blalock-Taussig shunt. Chest computed tomography (CT) performed on postoperative day 11 showed good patency of the shunt. However, on postoperative day 16, oxygen saturation suddenly dropped below 40%, and chest CT showed thrombotic occlusion of the shunt. Urgent thrombectomy was performed successfully. Examination of coagulation factors revealed low levels of both the amount and activity of protein C (27% and 31%, respectively). Diagnosis of heterozygous hereditary protein C deficiency was made, and the patient was placed on warfarin. She is currently in good condition.

Topics: Anticoagulants; Double Outlet Right Ventricle; Emergencies; Humans; Infant; Postoperative Complications; Protein C Deficiency; Pulmonary Valve Stenosis; Radiography, Thoracic; Thrombectomy; Thrombosis; Tomography, X-Ray Computed; Vascular Surgical Procedures; Warfarin

Topics: Anticoagulants; Blood Coagulation Factors; Emergencies; Guideline Adherence; Humans; Practice Guidelines as Topic; United Kingdom; Warfarin

Epistaxis is the most common nasal emergency and if nasal packing is required this commonly results in admission.. A literature search could find no published (UK) protocols for the management of this common condition in accident and emergency (A&E) departments. This paper presents a retrospective review of 116 patients with epistaxis, following implementation of the new peer reviewed protocol in June 2004.. Apart from cautery, 62 had nasal packing inserted. Only 17 required admission. Forty-six patients were discharged with nasal packing in situ and only seven (16 per cent) returned due to bleeding. The overall return rate was 11 per cent.. We feel this is a safe and logical protocol. Compared to mandatory admission after nasal pack insertion, we saved 39 admissions in five months. There were also the added benefits to patients of being able to recuperate at home rather than in hospital and avoidance of the risk of hospital acquired infection.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Clinical Protocols; Emergencies; Emergency Service, Hospital; England; Epistaxis; Female; Guideline Adherence; Hemostatic Techniques; Hospitalization; Humans; Male; Middle Aged; Patient Discharge; Peer Review, Health Care; Retrospective Studies; Tampons, Surgical; Warfarin

Topics: Anticoagulants; Emergencies; Femoral Neck Fractures; Humans; Injections, Intravenous; International Normalized Ratio; Preoperative Care; Time Factors; Vitamin K; Warfarin

Inferior shoulder dislocation or luxatio erecta is an exceedingly rare form of shoulder dislocation and compromises less than 0.5% of all shoulder dislocations. Furthermore, bilateral luxatio erecta is reported only nine times in the English literature. This paper documents the tenth case of bilateral luxatio erecta. This tenth patient suffered an axial load injury to his outstretched arms and displaced both humeral heads inferiorly. After closed reduction, the patient was discharged home on hospital day two. However, he developed an axillary vein thrombosis 3 days later and required anticoagulation therapy. This report reviews the mechanisms of injury associated with inferior shoulder dislocations as well as the presentation and treatment of luxatio erecta. The complication of axillary vein thrombosis and its treatment in this patient are discussed also.

Topics: Accidents, Traffic; Adult; Anticoagulants; Arm Injuries; Axillary Vein; Drug Therapy, Combination; Emergencies; Follow-Up Studies; Heparin, Low-Molecular-Weight; Humans; Male; Manipulation, Orthopedic; Postoperative Complications; Radiography; Shoulder Dislocation; Ultrasonography, Doppler; Venous Thrombosis; Warfarin; Weight-Bearing; Wounds, Nonpenetrating

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

We describe a case where danaparoid was used prophylactically in a high-risk twin pregnancy following the development of heparin-allergy while on prophylactic dalteparin. Danaparoid was substituted for dalteparin at 20 weeks of pregnancy following the development of a severe skin reaction while on the low molecular weight heparin. Although there was no significant fall in platelet count, an aggregation assay for heparin-induced thrombocytopaenia was positive. The skin lesions rapidly resolved following the change to subcutaneous danaparoid. Delivery was by emergency caesarian section at 35 weeks under a general anaesthetic, as a dose of danaparoid had been given 6 h prior to delivery. A sample of breast milk showed no anti-activated factor X activity. Danaparoid was continued post-delivery until the patient was fully warfarinized. To our knowledge, there are no previous reports of the use of danaparoid in this setting.

Topics: Adult; Anticoagulants; Cesarean Section; Chondroitin Sulfates; Dermatan Sulfate; Drug Combinations; Drug Eruptions; Emergencies; Female; Heparin; Heparitin Sulfate; Humans; Infant, Newborn; Injections, Subcutaneous; Platelet Count; Pregnancy; Pregnancy Complications, Hematologic; Pregnancy, High-Risk; Pregnancy, Multiple; Puerperal Disorders; Pulmonary Embolism; Thrombocytopenia; Thrombosis; Warfarin

Spinal epidural haematoma is an uncommon, but recognised, clinical entity that needs emergency management. The association of spinal epidural haematomata with warfarin therapy has been described and, in 1956, Alderman stated that this diagnosis should be entertained in any patient receiving anticoagulants presenting with low back pain or sciatic pain. The purpose of this case report is to increase the awareness of this entity among medical personnel and to stress the urgency of management.

Topics: Anticoagulants; Emergencies; Female; Hematoma, Epidural, Cranial; Humans; Magnetic Resonance Imaging; Middle Aged; Warfarin

Topics: Anticoagulants; Diagnosis, Differential; Emergencies; Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Humans; Recurrence; Thrombophlebitis; Time Factors; Warfarin

Topics: Adult; Anticoagulants; Drug Interactions; Emergencies; Female; Fibrin; Humans; Levonorgestrel; Pulmonary Embolism; Venous Thrombosis; Warfarin

The incidence of spontaneous intracranial haemorrhage has increased markedly in line with the increased use of oral anticoagulant agents. Recent guidelines for reversal of this acquired coagulation defect in an emergency have been established, but they are not adhered to in all centres. Our unit is referred between 20 and 60 patients per year (1994-1999) who are anticoagulated and require urgent neurosurgical intervention. In order to investigate this, we performed a prospective study using prothrombin complex concentrate (PCC). PCC was given to the first six patients with intracranial haemorrhage admitted to the neurosurgical unit requiring urgent correction of anticoagulation (Group 1) and compared with patients receiving standard treatment with fresh frozen plasma and vitamin K (Group 2). Mean International Normalised Ratios of Group 1 were 4.86 pretreatment and 1.32 posttreatment, and of Group 2 were 5.32 and 2.30, respectively. Results for complete reversal and reversal time were significant for PCC with p < 0.001. We recommend PCC for rapid and effective reversal of warfarin in life-threatening neurosurgical emergencies.

Topics: Adult; Aged; Anticoagulants; Blood Coagulation Factors; Cerebral Hemorrhage; Emergencies; Female; Hematoma, Subdural; Humans; International Normalized Ratio; Male; Middle Aged; Pilot Projects; Preoperative Care; Prospective Studies; Subarachnoid Hemorrhage; Vitamin K; Warfarin

Topics: Anticoagulants; Buttocks; Drug Eruptions; Emergencies; Female; Humans; Middle Aged; Necrosis; Pain; Skin; Venous Thrombosis; Warfarin

Topics: Aged; Anticoagulants; Blood Loss, Surgical; Colonic Neoplasms; Emergencies; Heart Valve Prosthesis; Humans; Male; Postoperative Period; Warfarin

Topics: Acute Disease; Adult; Catheter Ablation; Dilatation and Curettage; Emergencies; Endometrial Hyperplasia; Female; Humans; Hysterectomy; Middle Aged; Uterine Hemorrhage; Warfarin

Three patients underwent emergency operation for thrombotic obstruction of a bileaflet mechanical prosthesis (two St. Jude and one Duromedics) in the mitral position. The three valves were successfully thromboectomized with return to normal function. In 2 patients removal of the thrombus at the valve hinges was assisted by the use of a flexible fiberoptic choledochoscope. All 3 patients remain well 2 years after the procedure, maintained on a regimen of warfarin and dipyridamole.

Topics: Dipyridamole; Emergencies; Endoscopy, Digestive System; Fiber Optic Technology; Heart Valve Prosthesis; Humans; Mitral Valve; Prosthesis Design; Thrombectomy; Thrombosis; Warfarin

Heparin used in the treatment of thromboembolic disease may produce an immune response in the patient, leading to thrombocytopenia and even thrombosis. These complications may arise at any time after the institution of heparin therapy. The authors report a case of heparin-induced thrombocytopenia with thrombosis in a 70-year-old woman. The complication was treated successfully with thrombectomy and the administration of warfarin and ancrod, which is a natural fibrinolytic agent. The nature of heparin-induced thrombosis and the mechanism of action of ancrod are discussed. The authors emphasize that all patients receiving heparin therapy should be closely monitored to detect hematologic disorders and to prevent their sequelae. Ancrod provides a reasonable therapeutic option if thrombosis does occur.

Topics: Aged; Ancrod; Combined Modality Therapy; Emergencies; Female; Femoral Artery; Heparin; Humans; Iliac Artery; Postoperative Care; Reoperation; Thrombectomy; Thrombocytopenia; Thrombosis; Warfarin

To assess current strategies used to investigate and manage acute atrial fibrillation in hospital.. Prospective survey of all acute admissions over 6 months.. District general hospital serving a population of 230,000 in north east Glasgow.. 2686 patients admitted as emergency cases over 6 months.. Of the 2686 patients, 170 (age range 38-95, mean (SD) 73.5 (10.6) years; 70 men (41%) and 100 women (59%)) were admitted with atrial fibrillation. The principal underlying medical conditions were ischaemic heart disease in 79 (46.5%), rheumatic heart disease in 26 (15.3%), and thyroid disease in six (3.5%). Cardiac failure was present on admission in 61 (36%), cerebrovascular events in 23 (14%), and myocardial infarction in 17 (10%). Of those with a history of atrial fibrillation (102 (60%) including 10 with paroxysmal atrial fibrillation) treatment on admission included digoxin in 71 (70%), warfarin in 20 (20%), and aspirin in 17 (17%); the aspirin was predominantly given for concomitant vascular disease. The mean (SD) inpatient stay was 16 days (19.7) (range 1-154) largely due to the patients with stroke. Thyroid function tests were performed in only 63% and echocardiography in 33%. Overall, the rate of introduction of anticoagulation (seven patients) and attempted cardioversion (21 patient: 19 pharmacological and two electrical) was surprisingly low. Only 49 patients (34% of those not on warfarin) had contraindications to anticoagulation: these included peptic ulcer or gastrointestinal bleeding in 18 (12%), dementia in eight (6%), chronic renal failure or dialysis in eight (6%), and alcohol excess in four (3%).. Standard investigations were inadequately used in patients with atrial fibrillation and there was a reluctance to perform cardioversion or to start anticoagulant treatment.

Topics: Adult; Aged; Aged, 80 and over; Aspirin; Atrial Fibrillation; Digoxin; Echocardiography; Electric Countershock; Emergencies; Female; Hospitalization; Humans; Length of Stay; Male; Medical Audit; Middle Aged; Scotland; Thyroid Function Tests; Warfarin

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

Hepatic venous thrombosis (HVT) should be recognized as a distinct and highly lethal thrombotic complication of paroxysmal nocturnal hemoglobinuria. In a patient with fulminant onset prompt recognition of a triad of clinical, laboratory and liver scan findings facilitated early, aggressive and prolonged heparinization followed by coumadin maintenance, all with good results. Additionally a case of asymptomatic, smoldering HVT was unearthed by liver scan survey and confirmed by hepatic venogram; the patient was started on a regimen of Coumadin (crystalline sodium warfarin, Endo).

Topics: Budd-Chiari Syndrome; Emergencies; Hemoglobinuria, Paroxysmal; Heparin; Humans; Male; Middle Aged; Warfarin

Topics: Acute Disease; Adult; Aged; Emergencies; Gastrointestinal Hemorrhage; Hematoma; Humans; Hypoprothrombinemias; Intestinal Obstruction; Male; Middle Aged; Phenindione; Radiography; Warfarin