Feb 9, 2010
Emergency reversal of anticoagulation and antiplatelet therapies in neurosurgical patients
DOI: 10.3171/2009.7.JNS0982
Intracranial hemorrhage (ICH) is a common problem encountered by neurosurgeons. Patient outcomes are influenced by hematoma size, growth, location, and the timing of evacuation, when indicated. Patients may have abnormal coagulation due to pharmacological anticoagulation or coagulopathy due to underlying systemic disease or blood transfusions. Strategies to reestablish the integrity of the clotting cascade and platelet function assume a familiarity with these processes. As patients are increasingly treated with anticoagulants and antiplatelet agents, it is essential that the physicians who care for patients with ICH understand these pathways and recognize how they can be manipulated to restore hemostasis.
Which are these pathways?
A very ilustrative table can be found at 315 page ( table 2 ). This contets the most efective pathways in anticoagulatión and antiagregation reversal before emergency surgery.
warfarin
1. vitamin K, 5-10 mg IV
2. 3-factor PCC, 4000 IU
3. low-dose rFVIIa, 1.0 mg†
lab test:PT/INR
UFH (unfraccioned heparin)
1. stop infusion
2. protamine sulfate, 1 mg for each 100
U of active heparin
lab test:PTT
FFP contraindicated
2. slow administration (<5 mg/minute) to avoid prota-mine-
induced bronchoconstriction or hypotension
LMWH Low-molecular-weight heparin
1. protamine sulfate, 1 mg for each 1 mg of
LMWH
2. consider activated PCC (FEIBA)
3. consider rFVIIa
pentasaccharide
1. rFVIIa, 30–90 μg/kg anti-Xa assay
aspirin
1. 1 U platelet transfusion
2. consider DDAVP, 0.3 μg/kg
3. consider rFVIIa, 30–90 μg /kg
consider PFA-100
clopidogrel or ticlopidine 1. 2 U platelet transfusion
2. consider DDAVP, 0.3 μg/kg
3. consider rFVIIa, 30–90 μg/kg
lab test: consider platelet aggregometry